MEDICARE: MARY DELTA MCCONNELL 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	13283	OR

General Provider Information

NPI Number	:	1033236732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY DELTA MCCONNELL LMT

Provider Business Mailing Address
First Line	:	275 NORTHWOODS DRIVE
Second Line	:	PO BOX 1366
City	:	MERLIN
State	:	OR
Zip	:	97532
Country	:	US
Telephone Number	:	541-476-8599
Fax Number	:

Provider Business Practice Location Address
First Line	:	275 NORTHWOODS DRIVE
Second Line	:
City	:	MERLIN
State	:	OR
Zip	:	97532
Country	:	US
Telephone Number	:	541-476-8599
Fax Number	:

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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