Provider Demographics
NPI:1104689736
Name:BUTEYN, DEDRA (LPC-IT)
Entity type:Individual
Prefix:
First Name:DEDRA
Middle Name:
Last Name:BUTEYN
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5457 RED CLOVER TRL
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7291
Mailing Address - Country:US
Mailing Address - Phone:920-470-5407
Mailing Address - Fax:
Practice Address - Street 1:806 VALLEY RD STE 13
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1012
Practice Address - Country:US
Practice Address - Phone:920-872-7292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7067-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional