Provider Demographics
NPI:1417956632
Name:BUTLER, JOHN (LMSW, ACP, PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LMSW, ACP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4219
Mailing Address - Country:US
Mailing Address - Phone:940-723-4488
Mailing Address - Fax:940-723-0446
Practice Address - Street 1:1808 ROSE ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4219
Practice Address - Country:US
Practice Address - Phone:940-723-4488
Practice Address - Fax:940-723-0446
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX163461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120905OtherSUPERIOR
TX7173124OtherAETNA BEHAVIORAL HEALTH
TX120905OtherTTC CHIPS
TX200869OtherMHN
TX136320OtherVALUEOPTIONS
TX64688OtherCSHCN
TX255185OtherCOMPSYCH
TX00508EOtherBLUE CROSS BLUE SHIELD
TX063891801Medicaid
TX063891801Medicaid