MEDICARE: DAVIANA BUTLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	210407

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	210407	OTHER		ATHLETIC CERTIFICATION & TRAINING COMMISSION

General Provider Information

NPI Number	:	1700314747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVIANA BUTLER

Provider Business Mailing Address
First Line	:	49881 GRAND RIVER AVE
Second Line	:
City	:	WIXOM
State	:	MI
Zip	:	48393-3309
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	49881 GRAND RIVER AVE
Second Line	:
City	:	WIXOM
State	:	MI
Zip	:	48393-3309
Country	:	US
Telephone Number	:	248-229-4016
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2017
Last Update Date	:	06/02/2017

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Directions to “ DAVIANA BUTLER ” Practice Location

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