MEDICARE: MRS. SUSANNE LYNN NOVOTNY LMT, CDA

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	172M00000X	Mechanotherapist	MT112219	TX
2	225700000X	Massage Therapist	MT112219	TX

General Provider Information

NPI Number	:	1194019364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSANNE LYNN NOVOTNY LMT, CDA

Provider Business Mailing Address
First Line	:	2126 CRYSTAL DOWNS DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77450-8666
Country	:	US
Telephone Number	:	832-389-6692
Fax Number	:

Provider Business Practice Location Address
First Line	:	2126 CRYSTAL DOWNS DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77450-8666
Country	:	US
Telephone Number	:	832-389-6692
Fax Number	:

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

Provider Enumeration Date	:	06/06/2011
Last Update Date	:	06/13/2011

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