Provider Demographics
NPI:1770784902
Name:BUTLER, MARY ALISON (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ALISON
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 1:1410 PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-2956
Mailing Address - Country:US
Mailing Address - Phone:719-210-0168
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST STE 2508
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9924421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO492558Medicare PIN
COCOAAA4456Medicare PIN