MEDICARE: SHENIQUA MYRA LEGARE-BUTLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-23-274417	MD

General Provider Information

NPI Number	:	1376317206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHENIQUA MYRA LEGARE-BUTLER

Provider Business Mailing Address
First Line	:	1548 ARGYLE AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21217-2901
Country	:	US
Telephone Number	:	410-963-4728
Fax Number	:

Provider Business Practice Location Address
First Line	:	9505 REISTERSTOWN RD STE 2NW
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-4451
Country	:	US
Telephone Number	:	443-571-8489
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2023
Last Update Date	:	11/10/2023

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