MEDICARE: MR. GLEN ERICKSON 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	MA00014743	WA

General Provider Information

NPI Number	:	1003956962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GLEN ERICKSON LMT

Provider Business Mailing Address
First Line	:	607 TURNER ST NE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-4665
Country	:	US
Telephone Number	:	360-943-5140
Fax Number	:

Provider Business Practice Location Address
First Line	:	1217 4TH AVE E
Second Line	:	SUITE 200
City	:	OLYMPIA
State	:	WA
Zip	:	98506-4246
Country	:	US
Telephone Number	:	360-570-8151
Fax Number	:	360-943-6602

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	07/08/2007

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