Provider Demographics
NPI:1093718454
Name:BUTLER, ROBERT O (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:O
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 4TH ST
Mailing Address - Street 2:STE. 224
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3040
Mailing Address - Country:US
Mailing Address - Phone:707-582-4975
Mailing Address - Fax:707-763-3920
Practice Address - Street 1:2455 BENNETT VALLEY RD STE C210
Practice Address - Street 2:#224
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5671
Practice Address - Country:US
Practice Address - Phone:707-523-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS73381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70957FMedicaid
CAFHC03887FMedicaid
CA1598786352Medicaid
CA1356344758Medicaid
CA1598786352Medicaid
551803Medicare Oscar/Certification
CAZZZ73222ZMedicare PIN
CA051100Medicare Oscar/Certification
CA1356344758Medicaid