Provider Demographics
NPI:1366188351
Name:BUTLER, KRISTINA LOUISE (PHD)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:LOUISE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1653 W CONGRESS PARKWAY
Practice Address - Street 2:1200 KELLOGG
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-563-1465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010681103T00000X
IL071.010681103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist