Healthcare Provider Details

I. General information

NPI: 1659624526
Provider Name (Legal Business Name): MARY K. BUTLAK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 WALTON ST STE 200
SYRACUSE NY
13202-1887
US

IV. Provider business mailing address

219 E WILLIAMS ST
WATERLOO NY
13165-1510
US

V. Phone/Fax

Practice location:
  • Phone: 315-478-0380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number002291-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: