Healthcare Provider Details

I. General information

NPI: 1407761604
Provider Name (Legal Business Name): HANNAH BUTCKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 RIVERSIDE DR
PAWCATUCK CT
06379-2056
US

IV. Provider business mailing address

2389 MAIN ST STE 100
GLASTONBURY CT
06033-4617
US

V. Phone/Fax

Practice location:
  • Phone: 860-510-2792
  • Fax:
Mailing address:
  • Phone: 860-510-2792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number17542
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: