MEDICARE: ABIGAIL BUTLER AT,ATC

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	AT006347	OH
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1215419213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIGAIL BUTLER AT,ATC

Provider Business Mailing Address
First Line	:	512 FOREST ST
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44903-2014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	124 N LINDEN RD
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2616
Country	:	US
Telephone Number	:	330-458-9365
Fax Number	:

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

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	06/08/2022

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