Provider Demographics
NPI:1174361489
Name:BUTLER, SYDNEY
Entity type:Individual
Prefix:
First Name:SYDNEY
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 1:17 BASTILLE ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8551
Mailing Address - Country:US
Mailing Address - Phone:601-405-1104
Mailing Address - Fax:
Practice Address - Street 1:7570 OLD CANTON RD STE 102
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6100
Practice Address - Country:US
Practice Address - Phone:601-809-5324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-1179101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty