Provider Demographics
NPI:1912287459
Name:BUTTERFLY EFFECTS
Entity Type:Organization
Organization Name:BUTTERFLY EFFECTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISION
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:M
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-493-6621
Mailing Address - Street 1:PO BOX 6059
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6059
Mailing Address - Country:US
Mailing Address - Phone:180-069-2232
Mailing Address - Fax:800-465-3203
Practice Address - Street 1:1801 DALLAS AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7905
Practice Address - Country:US
Practice Address - Phone:180-069-2232
Practice Address - Fax:800-465-3203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC948-81-9464-MMedicaid