Provider Demographics
NPI:1174215495
Name:BUTLER, DEZIRAE
Entity type:Individual
Prefix:
First Name:DEZIRAE
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 1:854 WILMINGTON LN
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2208
Mailing Address - Country:US
Mailing Address - Phone:860-938-5404
Mailing Address - Fax:
Practice Address - Street 1:7108 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22231037106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician