Provider Demographics
NPI:1417060195
Name:BUTTE, MEGAN ELISE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ELISE
Last Name:BUTTE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MISS
Other - First Name:MEGAN
Other - Middle Name:ELISE
Other - Last Name:WALDREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:2120 119TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5442
Mailing Address - Country:US
Mailing Address - Phone:651-216-0801
Mailing Address - Fax:
Practice Address - Street 1:9630 GROVE CIR N STE 200
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-3492
Practice Address - Country:US
Practice Address - Phone:763-520-7870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer