Provider Demographics
NPI:1124544457
Name:BUTLER, ELLIS RAY II (LCAS-A)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:RAY
Last Name:BUTLER
Suffix:II
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:ELLIS
Other - Middle Name:RAY
Other - Last Name:BUTLER
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LCAS-A
Mailing Address - Street 1:521 MONTGROVE PL NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-6554
Mailing Address - Country:US
Mailing Address - Phone:980-319-4357
Mailing Address - Fax:
Practice Address - Street 1:536 SIGNAL HILL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4391
Practice Address - Country:US
Practice Address - Phone:704-872-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS20060101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)