Provider Demographics
NPI:1356644116
Name:IBUTU, BRENDA DORSCH (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:DORSCH
Last Name:IBUTU
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-2249
Mailing Address - Country:US
Mailing Address - Phone:410-789-6247
Mailing Address - Fax:410-789-8364
Practice Address - Street 1:3902 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:MD
Practice Address - Zip Code:21227-2249
Practice Address - Country:US
Practice Address - Phone:410-789-2647
Practice Address - Fax:410-789-8364
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3573101Y00000X, 101YA0400X, 101YM0800X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional