Provider Demographics
NPI:1730495763
Name:BUTLER, ANGELIQUE E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:E
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:713 SOUTH WEST STREET
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-0435
Mailing Address - Country:US
Mailing Address - Phone:417-399-1537
Mailing Address - Fax:
Practice Address - Street 1:1300 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4264
Practice Address - Country:US
Practice Address - Phone:417-761-5000
Practice Address - Fax:417-761-5011
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038788103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical