MEDICARE: DUSTIN COTTRELL 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	2601002079	MI

General Provider Information

NPI Number	:	1992162176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN COTTRELL ATC

Provider Business Mailing Address
First Line	:	33900 HARPER AVE STE 104
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48035-4258
Country	:	US
Telephone Number	:	586-350-2644
Fax Number	:	586-541-3735

Provider Business Practice Location Address
First Line	:	20905 E 12 MILE RD STE 200
Second Line	:
City	:	ROSEVILLE
State	:	MI
Zip	:	48066-6501
Country	:	US
Telephone Number	:	586-204-0070
Fax Number	:	586-204-0080

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

Provider Enumeration Date	:	01/19/2016
Last Update Date	:	03/03/2026

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