Provider Demographics
NPI:1598819518
Name:BUTLER, ELEANA MAIA (MSW)
Entity type:Individual
Prefix:
First Name:ELEANA
Middle Name:MAIA
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ROAD 4625
Mailing Address - Street 2:
Mailing Address - City:BLANCO
Mailing Address - State:NM
Mailing Address - Zip Code:87412-9743
Mailing Address - Country:US
Mailing Address - Phone:505-632-2138
Mailing Address - Fax:505-326-2557
Practice Address - Street 1:14 ROAD 4625
Practice Address - Street 2:
Practice Address - City:BLANCO
Practice Address - State:NM
Practice Address - Zip Code:87412-9743
Practice Address - Country:US
Practice Address - Phone:505-632-2138
Practice Address - Fax:505-326-2557
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA0850Medicaid