Provider Demographics
NPI:1629311394
Name:BUTLER, TATAVIA (LCSW)
Entity Type:Individual
Prefix:
First Name:TATAVIA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LCSW
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 3245
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94540-3245
Mailing Address - Country:US
Mailing Address - Phone:405-431-0833
Mailing Address - Fax:
Practice Address - Street 1:7707 SOUTH AUSTIN RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-8312
Practice Address - Country:US
Practice Address - Phone:818-570-6752
Practice Address - Fax:818-570-6752
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2022-10-27
Deactivation Date:2022-10-19
Deactivation Code:
Reactivation Date:2022-10-27
Provider Licenses
StateLicense IDTaxonomies
CA1019521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical