MEDICARE: EBONY DYCUS LMT

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	225700000X	Massage Therapist	MT136428	TX

General Provider Information

NPI Number	:	1477418549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY DYCUS LMT

Provider Business Mailing Address
First Line	:	680 W SAM HOUSTON PKWY S APT 117
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77042-1559
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9107 FM 723 RD
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-9215
Country	:	US
Telephone Number	:	317-454-4120
Fax Number	:

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

Provider Enumeration Date	:	12/19/2025
Last Update Date	:	12/19/2025

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