MEDICARE: MRS. AMANDA VIRGINIA BURLISON LMT, MMP

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	187	NV
2	225700000X	Massage Therapist	8828	TN

General Provider Information

NPI Number	:	1043447923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA VIRGINIA BURLISON LMT, MMP

Provider Business Mailing Address
First Line	:	1032 WILLOUGHBY STATION BLVD
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-7581
Country	:	US
Telephone Number	:	775-848-6603
Fax Number	:	877-711-6053

Provider Business Practice Location Address
First Line	:	1032 WILLOUGHBY STATION BLVD
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-7581
Country	:	US
Telephone Number	:	775-848-6603
Fax Number	:	877-711-6053

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

Provider Enumeration Date	:	06/17/2009
Last Update Date	:	02/13/2012

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