MEDICARE: MR. ELIJAH LEE SMITH LMT / MA

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	61386146	WA

General Provider Information

NPI Number	:	1538931472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ELIJAH LEE SMITH LMT / MA

Provider Business Mailing Address
First Line	:	5524 16TH AVE NE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-3415
Country	:	US
Telephone Number	:	510-915-1903
Fax Number	:

Provider Business Practice Location Address
First Line	:	3517 STONE WAY N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8923
Country	:	US
Telephone Number	:	510-915-1903
Fax Number	:

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

Provider Enumeration Date	:	10/24/2023
Last Update Date	:	10/24/2023

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