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NPI Code Detail

MEDICARE: LEAH WILSON CMT

MEDICARE: LEAH WILSON CMT
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
1225700000XMassage TherapistMT-00105535CO

General Provider Information

NPI Number : 1528405990
Entity Type Code : Individual
Provider Name (Legal Business Name) : LEAH WILSON CMT
Provider Business Mailing Address
First Line : 3942 IVYWOOD LN
Second Line :
City : PUEBLO
State : CO
Zip : 81005-2567
Country : US
Telephone Number : 719-248-9797
Fax Number :
Provider Business Practice Location Address
First Line : 3942 IVYWOOD LN
Second Line :
City : PUEBLO
State : CO
Zip : 81005-2567
Country : US
Telephone Number : 719-248-9797
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/25/2013
Last Update Date : 05/25/2013

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