Provider Demographics
NPI:1710565486
Name:BUTLER, MATTIE (PLPC)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 GETWELL RD BLDG B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6455
Mailing Address - Country:US
Mailing Address - Phone:662-349-2979
Mailing Address - Fax:662-349-2978
Practice Address - Street 1:5915 GETWELL RD BLDG B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6455
Practice Address - Country:US
Practice Address - Phone:662-349-2979
Practice Address - Fax:662-349-2978
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0619101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional