=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215419213
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL BUTLER AT,ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2018
-----------------------------------------------------
Last Update Date | 06/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 N LINDEN RD
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906-2616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-458-9365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 512 FOREST ST
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44903-2014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT006347
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------