Provider Demographics
NPI:1265920805
Name:BUTLER, SHAWN W (HIS)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:W
Last Name:BUTLER
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1064
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418-1064
Mailing Address - Country:US
Mailing Address - Phone:757-787-2311
Mailing Address - Fax:
Practice Address - Street 1:9502 HOSPITAL AVE.
Practice Address - Street 2:
Practice Address - City:NASSAWADOX
Practice Address - State:VA
Practice Address - Zip Code:23413
Practice Address - Country:US
Practice Address - Phone:757-710-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101001967237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2101001967OtherHEARING INSTRUMENT SPECIALIST LICENSE