Provider Demographics
NPI:1215733043
Name:BUTLER, SHANETTINE
Entity type:Individual
Prefix:
First Name:SHANETTINE
Middle Name:
Last Name:BUTLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 E 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409
Mailing Address - Country:US
Mailing Address - Phone:219-888-9468
Mailing Address - Fax:219-245-6330
Practice Address - Street 1:843 E 49TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-2801
Practice Address - Country:US
Practice Address - Phone:219-888-9468
Practice Address - Fax:219-245-6330
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician