Provider Demographics
NPI:1770039273
Name:BUTLER, SEAN
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4098 MAIN ST STE 9
Mailing Address - Street 2:
Mailing Address - City:CHINCOTEAGUE
Mailing Address - State:VA
Mailing Address - Zip Code:23336-2466
Mailing Address - Country:US
Mailing Address - Phone:757-891-5871
Mailing Address - Fax:
Practice Address - Street 1:1519 MARKET ST
Practice Address - Street 2:
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-1711
Practice Address - Country:US
Practice Address - Phone:757-891-5871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225091041C0700X
VA09040115211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD614064500Medicaid
MD520202702Medicaid