Provider Demographics
NPI:1265460588
Name:BUTRYM, JAMES JOHN (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:JOHN
Last Name:BUTRYM
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 LAKE AVE N
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:508-856-5944
Mailing Address - Fax:
Practice Address - Street 1:5 TATNUCK GDNS
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01602-1220
Practice Address - Country:US
Practice Address - Phone:508-798-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1142941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJB57349Medicaid