Provider Demographics
NPI:1023774114
Name:BUTLER, KENNETH MICHAEL (SAC-IT, NREMT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:BUTLER
Suffix:
Gender:M
Credentials:SAC-IT, NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1681 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6720
Mailing Address - Country:US
Mailing Address - Phone:414-273-8484
Mailing Address - Fax:
Practice Address - Street 1:1681 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-6720
Practice Address - Country:US
Practice Address - Phone:414-273-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIR1032909146N00000X
WI19378-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic