Healthcare Provider Details

I. General information

NPI: 1265460588
Provider Name (Legal Business Name): JAMES JOHN BUTRYM LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 TATNUCK GDNS
WORCESTER MA
01602-1220
US

IV. Provider business mailing address

55 LAKE AVE N
WORCESTER MA
01655-0002
US

V. Phone/Fax

Practice location:
  • Phone: 508-798-8305
  • Fax:
Mailing address:
  • Phone: 508-856-5944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114294
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierJB57349
Identifier TypeMEDICAID
Identifier StateRI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: