Provider Demographics
NPI:1891270922
Name:BUTCHER, MOLLY LAINE
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:LAINE
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:LAINE
Other - Last Name:BARLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3900 UNIVERISTY BLVD WTB 128
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-6601
Practice Address - Country:US
Practice Address - Phone:903-565-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty