Provider Demographics
NPI:1194129445
Name:GRANT BUTTERBAUGH PHD LLC
Entity type:Organization
Organization Name:GRANT BUTTERBAUGH PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:BUTTERBAUGH
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:504-309-9855
Mailing Address - Street 1:3525 PRYTANIA ST
Mailing Address - Street 2:SUITE 309
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3500
Mailing Address - Country:US
Mailing Address - Phone:504-309-9855
Mailing Address - Fax:504-814-4346
Practice Address - Street 1:3525 PRYTANIA ST
Practice Address - Street 2:SUITE 309
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-3500
Practice Address - Country:US
Practice Address - Phone:504-309-9855
Practice Address - Fax:504-814-4346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA681103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty