Provider Demographics
NPI:1871205989
Name:BUTLER, CAROL O
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:O
Last Name: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 1:101 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414
Mailing Address - Country:US
Mailing Address - Phone:979-245-2008
Mailing Address - Fax:979-217-8829
Practice Address - Street 1:1700 GOLDEN AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-3122
Practice Address - Country:US
Practice Address - Phone:979-245-2008
Practice Address - Fax:979-217-8829
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT80119OtherDIETICIAN