Provider Demographics
NPI:1104267491
Name:BUTH, NICOLE B (MS, CF-SLP)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:B
Last Name:BUTH
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N. LAKE HAVASU AVE
Mailing Address - Street 2:STE #100
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404
Mailing Address - Country:US
Mailing Address - Phone:928-854-5439
Mailing Address - Fax:928-854-5440
Practice Address - Street 1:1515 N. LAKE HAVASU AVE
Practice Address - Street 2:STE #100
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86404
Practice Address - Country:US
Practice Address - Phone:928-854-5439
Practice Address - Fax:928-854-5440
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP8446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ832107Medicaid