MEDICARE: CORINNE N DEPRIEST 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	MT-23150	AZ

General Provider Information

NPI Number	:	1093212714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORINNE N DEPRIEST LMT

Provider Business Mailing Address
First Line	:	1580 E GRAN CIRCULO
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9233
Country	:	US
Telephone Number	:	928-542-6491
Fax Number	:

Provider Business Practice Location Address
First Line	:	1580 E GRAN CIRCULO
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9233
Country	:	US
Telephone Number	:	928-542-6491
Fax Number	:

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

Provider Enumeration Date	:	04/09/2018
Last Update Date	:	04/09/2018

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Directions to “ CORINNE N DEPRIEST LMT” Practice Location

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