Healthcare Provider Details

I. General information

NPI: 1528143625
Provider Name (Legal Business Name): BERNARD BUTTS LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 E COTTONWOOD LN
CASA GRANDE AZ
85222-2514
US

IV. Provider business mailing address

265 N GILBERT RD #1052
MESA AZ
85203-8248
US

V. Phone/Fax

Practice location:
  • Phone: 520-836-1688
  • Fax: 520-876-1796
Mailing address:
  • Phone: 480-251-6865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10497
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: