Provider Demographics
NPI:1679054472
Name:BUTTOLPH, LITA (LAC)
Entity type:Individual
Prefix:DR
First Name:LITA
Middle Name:
Last Name:BUTTOLPH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6322 SE 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-7039
Mailing Address - Country:US
Mailing Address - Phone:503-358-0739
Mailing Address - Fax:
Practice Address - Street 1:3007 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4026
Practice Address - Country:US
Practice Address - Phone:503-445-7115
Practice Address - Fax:503-445-7116
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC188773171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist