Provider Demographics
NPI:1982834495
Name:BUTLER, ROBERT LEON (LADC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEON
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 FULLER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4832
Mailing Address - Country:US
Mailing Address - Phone:612-229-0795
Mailing Address - Fax:
Practice Address - Street 1:1121 JACKSON ST NE
Practice Address - Street 2:105
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1672
Practice Address - Country:US
Practice Address - Phone:612-977-1814
Practice Address - Fax:612-236-1701
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302499101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)