Provider Demographics
NPI:1528461480
Name:BUTLER, ANTWAN RAHEEM (LCSW-BACS)
Entity type:Individual
Prefix:MR
First Name:ANTWAN
Middle Name:RAHEEM
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LCSW-BACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6808 JEFFERSON PAIGE ROAD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119
Mailing Address - Country:US
Mailing Address - Phone:318-564-2208
Mailing Address - Fax:318-525-9007
Practice Address - Street 1:6808 JEFFERSON PAIGE RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-3302
Practice Address - Country:US
Practice Address - Phone:318-564-2208
Practice Address - Fax:318-525-9007
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA90841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical