Healthcare Provider Details

I. General information

NPI: 1396933404
Provider Name (Legal Business Name): ROEATHEA BUTLER LICSW, LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MERCANTILE LN STE 129-62
LARGO MD
20774-5327
US

IV. Provider business mailing address

307 ZELMA AVE
CAPITOL HEIGHTS MD
20743-3124
US

V. Phone/Fax

Practice location:
  • Phone: 301-388-8987
  • Fax:
Mailing address:
  • Phone: 301-350-6219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50078194
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13408
License Number StateMD

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: