Healthcare Provider Details

I. General information

NPI: 1700128212
Provider Name (Legal Business Name): DANIEL WILLEN MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PAUL BROWN STADIUM
CINCINNATI OH
45202-3418
US

IV. Provider business mailing address

1 PAUL BROWN STADIUM
CINCINNATI OH
45202-3418
US

V. Phone/Fax

Practice location:
  • Phone: 513-455-8473
  • Fax: 513-455-8477
Mailing address:
  • Phone: 513-455-8473
  • Fax: 513-455-8477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-1629
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: