MEDICARE: MICHELE GULLO-BAKOWSKI 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	025754	NY

General Provider Information

NPI Number	:	1811369606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE GULLO-BAKOWSKI LMT

Provider Business Mailing Address
First Line	:	7540 SALT RD
Second Line	:
City	:	CLARENCE CENTER
State	:	NY
Zip	:	14032-9655
Country	:	US
Telephone Number	:	716-868-9975
Fax Number	:

Provider Business Practice Location Address
First Line	:	10440 MAIN ST
Second Line	:	STE 2
City	:	CLARENCE
State	:	NY
Zip	:	14031-1627
Country	:	US
Telephone Number	:	716-868-9975
Fax Number	:

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

Provider Enumeration Date	:	10/20/2015
Last Update Date	:	10/20/2015

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