Provider Demographics
NPI:1265901243
Name:BUTLER, CALVENA MONIQUE
Entity type:Individual
Prefix:
First Name:CALVENA
Middle Name:MONIQUE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:978 SPRINGFIELD ST APT C
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3038
Mailing Address - Country:US
Mailing Address - Phone:909-452-4139
Mailing Address - Fax:
Practice Address - Street 1:1350 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5201
Practice Address - Country:US
Practice Address - Phone:909-596-5921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35082167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician