Basic Information
| Provider Information | |||||||||
| NPI: | 1336557172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | STUART | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PSYCHOLOGY BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6623 1/2 GAVIOTA AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE BALBOA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914065942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139152249 | ||||||||
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| Practice Location | |||||||||
| Address1: | 566 S BRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913404002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188980223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2014 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.