Healthcare Provider Details

I. General information

NPI: 1972733723
Provider Name (Legal Business Name): EBONI TIANA BUTLER PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EBONI TIANA BUTLER LPC

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 06/12/2024
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4031 FOREST TEAL CT
FRESNO TX
77545-8648
US

IV. Provider business mailing address

4031 FOREST TEAL CT
FRESNO TX
77545-8648
US

V. Phone/Fax

Practice location:
  • Phone: 281-431-5323
  • Fax: 281-431-5324
Mailing address:
  • Phone: 281-431-5323
  • Fax: 281-431-5324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number62492
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number34589
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: