Provider Demographics
NPI:1376317206
Name:LEGARE-BUTLER, SHENIQUA MYRA
Entity Type:Individual
Prefix:
First Name:SHENIQUA
Middle Name:MYRA
Last Name:LEGARE-BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 ARGYLE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-2901
Mailing Address - Country:US
Mailing Address - Phone:410-963-4728
Mailing Address - Fax:
Practice Address - Street 1:9505 REISTERSTOWN RD STE 2NW
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4451
Practice Address - Country:US
Practice Address - Phone:443-571-8489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-23-274417106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty