Provider Demographics
NPI:1922880426
Name:BUTLER, KIESHA MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIESHA
Middle Name:MARIE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-1808
Mailing Address - Country:US
Mailing Address - Phone:330-957-4798
Mailing Address - Fax:234-678-5547
Practice Address - Street 1:1653 MERRIMAN RD STE 106
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5275
Practice Address - Country:US
Practice Address - Phone:330-957-4798
Practice Address - Fax:234-678-5547
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171400000X
174H00000X
OHESTI.200515247200000X, 174400000X
OHESTS.200111261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center