Provider Demographics
NPI:1447087069
Name:CLARK BUTLER, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CLARK BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-1167
Mailing Address - Country:US
Mailing Address - Phone:317-850-7768
Mailing Address - Fax:
Practice Address - Street 1:1806 IN-234
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040
Practice Address - Country:US
Practice Address - Phone:317-485-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool