Basic Information
| Provider Information | |||||||||
| NPI: | 1669716163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLERBRANT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 521 NE 25TH AVE | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344707034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524017916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 521 NE 25TH AVE | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344707034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524017916 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2012 | ||||||||
| LastUpdateDate: | 05/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA2591 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 010732300 | 05 | FL | MEDICAID |