Provider Demographics
NPI:1912510140
Name:MABUTI, EDNA (OTR/L)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:MABUTI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 RALEIGH DR APT 1207
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-7975
Mailing Address - Country:US
Mailing Address - Phone:678-315-8280
Mailing Address - Fax:
Practice Address - Street 1:1020 RALEIGH DR APT 1207
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007-7975
Practice Address - Country:US
Practice Address - Phone:678-315-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120687225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist