Provider Demographics
NPI:1871701003
Name:BUTEHORN, LORETTA (PHD,CCH)
Entity type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:
Last Name:BUTEHORN
Suffix:
Gender:F
Credentials:PHD,CCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 NEPONSET AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3103
Mailing Address - Country:US
Mailing Address - Phone:617-529-2806
Mailing Address - Fax:
Practice Address - Street 1:345 NEPONSET AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3103
Practice Address - Country:US
Practice Address - Phone:617-529-2806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3933103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO3922OtherBCBS