Basic Information
| Provider Information | |||||||||
| NPI: | 1801159249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIFENBURG | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12 JUDD LN | ||||||||
| Address2: | |||||||||
| City: | WYNANTSKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121988016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183787489 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 435 4TH ST | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121805324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182716777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2012 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.