Provider Demographics
NPI:1073909818
Name:BUTOLPH, TEDI (LCSW)
Entity Type:Individual
Prefix:
First Name:TEDI
Middle Name:
Last Name:BUTOLPH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 WYOMING ST # 1
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78203-1318
Mailing Address - Country:US
Mailing Address - Phone:707-496-3772
Mailing Address - Fax:
Practice Address - Street 1:1115 MISSION RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78210-4505
Practice Address - Country:US
Practice Address - Phone:210-533-3504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX554071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical