MEDICARE: THERAPEUTIC BODYWORK & MASSAGE, INC

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 41685	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C3868	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1902025711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPEUTIC BODYWORK & MASSAGE, INC

Provider Business Mailing Address
First Line	:	303 E 7TH ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-3032
Country	:	US
Telephone Number	:	850-747-1277
Fax Number	:	850-784-4441

Provider Business Practice Location Address
First Line	:	303 E 7TH ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-3032
Country	:	US
Telephone Number	:	850-747-1277
Fax Number	:	850-784-4441

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. MARY ELIZABETH FUSILIER
Credential	:	L.M.T.
Telephone Number	:	850-747-1277

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	08/22/2020

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