Provider Demographics
NPI:1902417173
Name:BUTCHER, SHELBY LEIGH (LMT)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LEIGH
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6740 BLACK WING DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-2356
Mailing Address - Country:US
Mailing Address - Phone:469-636-6314
Mailing Address - Fax:
Practice Address - Street 1:6740 BLACK WING DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-2356
Practice Address - Country:US
Practice Address - Phone:469-636-6314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT132363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist