Provider Demographics
NPI:1336253277
Name:BUTKOVICH, LORI LANE (RN,CS-P)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:LANE
Last Name:BUTKOVICH
Suffix:
Gender:F
Credentials:RN,CS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 THETFORD RD
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-8131
Mailing Address - Country:US
Mailing Address - Phone:410-494-1804
Mailing Address - Fax:
Practice Address - Street 1:500 N ROLLING RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4134
Practice Address - Country:US
Practice Address - Phone:410-869-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRN113421101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health