Provider Demographics
NPI:1962950022
Name:BUTLER, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
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 1:80 W 44TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-6957
Mailing Address - Country:US
Mailing Address - Phone:440-319-6899
Mailing Address - Fax:
Practice Address - Street 1:2801 C CT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4577
Practice Address - Country:US
Practice Address - Phone:440-998-4210
Practice Address - Fax:440-998-2247
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1600675104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker