Provider Demographics
NPI:1861570293
Name:BUTKUS, MARK STANLEY (LISW-CP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:STANLEY
Last Name:BUTKUS
Suffix:
Gender:M
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 BUCKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-1313
Mailing Address - Country:US
Mailing Address - Phone:803-369-3743
Mailing Address - Fax:
Practice Address - Street 1:3809 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-3533
Practice Address - Country:US
Practice Address - Phone:803-786-1844
Practice Address - Fax:803-754-7783
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0071591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQM0689Medicaid
SCQM0689Medicaid