MEDICARE: MS. SUSAN VITTNER MT

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	MT4173	ME

General Provider Information

NPI Number	:	1245561570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN VITTNER MT

Provider Business Mailing Address
First Line	:	67 NORTH ST
Second Line	:	1ST FLOOR
City	:	PORTLAND
State	:	ME
Zip	:	04101-2777
Country	:	US
Telephone Number	:	210-559-6419
Fax Number	:

Provider Business Practice Location Address
First Line	:	67 NORTH ST
Second Line	:	1ST FLOOR
City	:	PORTLAND
State	:	ME
Zip	:	04101-2777
Country	:	US
Telephone Number	:	210-559-6419
Fax Number	:

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

Provider Enumeration Date	:	01/27/2010
Last Update Date	:	01/27/2010

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