MEDICARE: KAWONNA PITTMAN MASSAGE THERAPIST

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NONE	OTHER		NONE

General Provider Information

NPI Number	:	1275191538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAWONNA PITTMAN MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	16048 HACKETT ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1800
Country	:	US
Telephone Number	:	313-758-8955
Fax Number	:

Provider Business Practice Location Address
First Line	:	15400 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-4124
Country	:	US
Telephone Number	:	313-758-8955
Fax Number	:

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

Provider Enumeration Date	:	06/03/2019
Last Update Date	:	06/03/2019

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Directions to “ KAWONNA PITTMAN MASSAGE THERAPIST” Practice Location

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