Provider Demographics
NPI:1346003456
Name:BUTHORN, JOHN KEVIN (LMSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KEVIN
Last Name:BUTHORN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3300
Mailing Address - Country:US
Mailing Address - Phone:718-966-0317
Mailing Address - Fax:
Practice Address - Street 1:12 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3300
Practice Address - Country:US
Practice Address - Phone:718-966-0317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120496-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker