Provider Demographics
NPI:1487612941
Name:BUTLER, SUSAN REIS (DOCTORATE)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:REIS
Last Name:BUTLER
Suffix:
Gender:F
Credentials:DOCTORATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7654 RIVER WALK CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-5830
Mailing Address - Country:US
Mailing Address - Phone:314-846-9616
Mailing Address - Fax:314-846-3531
Practice Address - Street 1:12962 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2915
Practice Address - Country:US
Practice Address - Phone:314-849-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYO 1451103TC1900X, 103TF0000X, 103TP2701X, 103T00000X
MOPYO1451103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy