Healthcare Provider Details

I. General information

NPI: 1033519434
Provider Name (Legal Business Name): GRACE MATHESON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7176 HWY 93
LAKESIDE MT
59922
US

IV. Provider business mailing address

PO BOX 9644
KALISPELL MT
59904-2644
US

V. Phone/Fax

Practice location:
  • Phone: 406-871-0634
  • Fax:
Mailing address:
  • Phone: 406-871-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT-1146
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: