Provider Demographics
NPI:1316112626
Name:BUTTIKOFER, DOUGLAS JOHN (MA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JOHN
Last Name:BUTTIKOFER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W BROADWAY AVE
Mailing Address - Street 2:SUITE 111 UNIT 41
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3264
Mailing Address - Country:US
Mailing Address - Phone:641-919-0647
Mailing Address - Fax:
Practice Address - Street 1:607 W BROADWAY AVE
Practice Address - Street 2:SUITE 111 UNIT 41
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-3264
Practice Address - Country:US
Practice Address - Phone:641-919-0647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0415101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health