MEDICARE: MARIESHA D WATTERS 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	KY2009	KY

General Provider Information

NPI Number	:	1437556214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIESHA D WATTERS LMT

Provider Business Mailing Address
First Line	:	618 NAKOMI DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-2104
Country	:	US
Telephone Number	:	304-634-5501
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 LEESTOWN RD STE 338
Second Line	:	BAKHAUS BLDG
City	:	LEXINGTON
State	:	KY
Zip	:	40511-2047
Country	:	US
Telephone Number	:	859-317-8295
Fax Number	:

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

Provider Enumeration Date	:	11/22/2014
Last Update Date	:	11/22/2014

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