Basic Information
| Provider Information | |||||||||
| NPI: | 1073126389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTERBAUGH | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LD, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228068 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 COMMONS BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454313834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374017575 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2020 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1006X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic |
ID Information
| ID | Type | State | Issuer | Description | 0421279 | 05 | OH | MEDICAID |