Provider Demographics
NPI:1841803038
Name:ELLIS BUTLER, PH.D., LLC
Entity Type:Organization
Organization Name:ELLIS BUTLER, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-738-3655
Mailing Address - Street 1:148 WESMINSTER CT
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28146-7456
Mailing Address - Country:US
Mailing Address - Phone:704-431-2299
Mailing Address - Fax:
Practice Address - Street 1:507 W INNES ST STE 270
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-4265
Practice Address - Country:US
Practice Address - Phone:704-738-3655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124544457Medicaid