Healthcare Provider Details

I. General information

NPI: 1477418549
Provider Name (Legal Business Name): EBONY DYCUS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9107 FM 723 RD
RICHMOND TX
77406-9215
US

IV. Provider business mailing address

680 W SAM HOUSTON PKWY S APT 117
HOUSTON TX
77042-1559
US

V. Phone/Fax

Practice location:
  • Phone: 317-454-4120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT136428
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: