Healthcare Provider Details

I. General information

NPI: 1154934008
Provider Name (Legal Business Name): MICHELLE J BUTCHER RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 STONE HILL DR
BRENHAM TX
77833-5630
US

IV. Provider business mailing address

359 STONE HILL DR
BRENHAM TX
77833-5630
US

V. Phone/Fax

Practice location:
  • Phone: 915-843-7649
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number86115892
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: