Healthcare Provider Details

I. General information

NPI: 1295383404
Provider Name (Legal Business Name): VINCENT BERNARD BUTCHER SR. MS, MRE, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date: 09/02/2019
Reactivation Date: 11/04/2019

III. Provider practice location address

420 WHEELIS ST
WEST MONROE LA
71292-3940
US

IV. Provider business mailing address

PO BOX 792
BASTROP LA
71221-0792
US

V. Phone/Fax

Practice location:
  • Phone: 318-556-8455
  • Fax: 318-556-8456
Mailing address:
  • Phone: 318-283-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8095
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: