Provider Demographics
NPI:1902029739
Name:BUTLER, CHARLES EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6845 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3500
Mailing Address - Country:US
Mailing Address - Phone:704-364-4333
Mailing Address - Fax:704-849-2376
Practice Address - Street 1:6845 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3500
Practice Address - Country:US
Practice Address - Phone:704-364-4333
Practice Address - Fax:704-849-2376
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0029351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003730Medicaid
NC6003730Medicaid