MEDICARE: ROBERTA MARINA GRANT 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	MA 00020199	WA
2	225700000X	Massage Therapist	10856	OR
3	101YM0800X	Mental Health Counselor	60836397	WA

General Provider Information

NPI Number	:	1538488390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERTA MARINA GRANT LMT

Provider Business Mailing Address
First Line	:	208 WEST STEUBEN
Second Line	:
City	:	BINGEN
State	:	WA
Zip	:	98605-0000
Country	:	US
Telephone Number	:	541-490-9794
Fax Number	:

Provider Business Practice Location Address
First Line	:	208 WEST STEUBEN
Second Line	:
City	:	BINGEN
State	:	WA
Zip	:	98605-0000
Country	:	US
Telephone Number	:	541-490-9794
Fax Number	:

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

Provider Enumeration Date	:	05/19/2010
Last Update Date	:	10/01/2020

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