Provider Demographics
NPI:1972742096
Name:BUTCHER CLOYD, LISA RENEE (MM, MA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENEE
Last Name:BUTCHER CLOYD
Suffix:
Gender:F
Credentials:MM, MA
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:BUTCHER-PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:909 FULTON ST SE FL 4
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-4800
Mailing Address - Country:US
Mailing Address - Phone:612-626-5900
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE FL 4
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-626-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3167-154235Z00000X
MN8427235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1972742096Medicaid