Provider Demographics
NPI:1326414707
Name:IVORY-BUTLER, PATRICE (LLMSW)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:
Last Name:IVORY-BUTLER
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4256
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46634-4256
Mailing Address - Country:US
Mailing Address - Phone:574-386-3374
Mailing Address - Fax:
Practice Address - Street 1:1615 N KENMORE ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-4256
Practice Address - Country:US
Practice Address - Phone:574-386-3374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010985181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical