MEDICARE: KOLLEEN K KOHLRUS LMP

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	MA00004101	WA

General Provider Information

NPI Number	:	1356460398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOLLEEN K KOHLRUS LMP

Provider Business Mailing Address
First Line	:	3301 NE 11TH ST
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98056-3452
Country	:	US
Telephone Number	:	206-280-3519
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 STORKSON RD BLDG 2-B
Second Line	:
City	:	CLINTON
State	:	WA
Zip	:	98236-9514
Country	:	US
Telephone Number	:	360-221-8552
Fax Number	:

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

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	11/24/2015

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