Provider Demographics
NPI:1942569090
Name:MATT F BUTRYN, PHD, LLC
Entity Type:Organization
Organization Name:MATT F BUTRYN, PHD, LLC
Other - Org Name:ATHENS NEUROPSYCHOLOGY AND COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:F
Authorized Official - Last Name:BUTRYN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-548-0018
Mailing Address - Street 1:1 HUNTINGTON RD
Mailing Address - Street 2:SUITE 802
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7204
Mailing Address - Country:US
Mailing Address - Phone:706-548-0018
Mailing Address - Fax:
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:SUITE 802
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-548-0018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2503103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000918222AMedicaid
GA000918222AMedicaid