Provider Demographics
NPI:1720628712
Name:BUTLER, MARISELA (BI)
Entity type:Individual
Prefix:
First Name:MARISELA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:BI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 W 4700 S
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-4311
Mailing Address - Country:US
Mailing Address - Phone:208-604-7118
Mailing Address - Fax:
Practice Address - Street 1:2128 W 4700 S
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-4311
Practice Address - Country:US
Practice Address - Phone:208-604-7118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty