Healthcare Provider Details

I. General information

NPI: 1861570293
Provider Name (Legal Business Name): MARK STANLEY BUTKUS LISW-CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3809 ROSEWOOD DR
COLUMBIA SC
29205-3533
US

IV. Provider business mailing address

6542 BUCKFIELD DR
COLUMBIA SC
29206-1313
US

V. Phone/Fax

Practice location:
  • Phone: 803-786-1844
  • Fax: 803-754-7783
Mailing address:
  • Phone: 803-369-3743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number007159
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: