MEDICARE: STEPHANIE ANN MATLOCK LMT, CHAA

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	33.015817	OH

General Provider Information

NPI Number	:	1295242741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE ANN MATLOCK LMT, CHAA

Provider Business Mailing Address
First Line	:	25001 EMERY RD BLDG 25E
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-5626
Country	:	US
Telephone Number	:	216-285-4070
Fax Number	:	216-201-5230

Provider Business Practice Location Address
First Line	:	25001 EMERY RD BLDG 25E
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-5626
Country	:	US
Telephone Number	:	216-285-4070
Fax Number	:	216-201-5230

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

Provider Enumeration Date	:	01/05/2018
Last Update Date	:	01/05/2018

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