MEDICARE: MACHELLE H PHILLIPS LMT, MLD-C

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	7390	LA

General Provider Information

NPI Number	:	1396349940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACHELLE H PHILLIPS LMT, MLD-C

Provider Business Mailing Address
First Line	:	1505 COMMON ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-6131
Country	:	US
Telephone Number	:	337-853-0944
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 COMMON ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-6131
Country	:	US
Telephone Number	:	337-764-0989
Fax Number	:

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

Provider Enumeration Date	:	11/24/2020
Last Update Date	:	11/24/2020

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