MEDICARE: ARIEL LEILANI FONSECA 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	61173178	WA

General Provider Information

NPI Number	:	1720851173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ARIEL LEILANI FONSECA LMT

Provider Business Mailing Address
First Line	:	21651 E COUNTRY VISTA DR STE F
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-7709
Country	:	US
Telephone Number	:	509-319-2310
Fax Number	:	509-319-2341

Provider Business Practice Location Address
First Line	:	21651 E COUNTRY VISTA DR STE F
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-7709
Country	:	US
Telephone Number	:	509-319-2310
Fax Number	:	509-319-2341

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

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	11/14/2023

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