Provider Demographics
NPI:1548848070
Name:BUTLER, MELISSA JEAN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 MENTONE AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3375
Mailing Address - Country:US
Mailing Address - Phone:908-489-6663
Mailing Address - Fax:
Practice Address - Street 1:1023 N HOLLYWOOD WAY STE 4B
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2539
Practice Address - Country:US
Practice Address - Phone:424-835-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA147353106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner