Provider Demographics
NPI:1790317931
Name:BUTHELEZI, MIRIAM SELAH (LMFTA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:SELAH
Last Name:BUTHELEZI
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:SELAH
Other - Last Name:BUTHELEZI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFTA
Mailing Address - Street 1:120 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 W 7TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404
Practice Address - Country:US
Practice Address - Phone:812-269-6966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99096527A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist