Provider Demographics
NPI:1295383404
Name:BUTCHER, VINCENT BERNARD SR
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:BERNARD
Last Name:BUTCHER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:RAYVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71269-2576
Mailing Address - Country:US
Mailing Address - Phone:318-728-2000
Mailing Address - Fax:
Practice Address - Street 1:622 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6211
Practice Address - Country:US
Practice Address - Phone:318-398-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2024-02-27
Deactivation Date:2019-09-02
Deactivation Code:
Reactivation Date:2019-11-04
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA8095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator