Provider Demographics
NPI:1912688904
Name:BUTCHER, RICHARD ROSS
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ROSS
Last Name:BUTCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 W DENTON LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-3070
Mailing Address - Country:US
Mailing Address - Phone:602-253-0759
Mailing Address - Fax:
Practice Address - Street 1:1626 W DENTON LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3070
Practice Address - Country:US
Practice Address - Phone:602-253-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLH10009405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional