Provider Demographics
NPI:1104594464
Name:BUTLER, SHANIQUA T (BCBA)
Entity type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:T
Last Name:BUTLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 N PARKDALE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-2927
Mailing Address - Country:US
Mailing Address - Phone:903-780-4720
Mailing Address - Fax:
Practice Address - Street 1:8720 MAIN ST
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-3079
Practice Address - Country:US
Practice Address - Phone:469-803-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-21-52690103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-52690OtherBACB