MEDICARE: EMILY ROSE BRANSTROM 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	MA60887838	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA60887838	OTHER	WA	N/A

General Provider Information

NPI Number	:	1316501240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY ROSE BRANSTROM LMT

Provider Business Mailing Address
First Line	:	15208 10TH DR NW
Second Line	:
City	:	MARYSVILLE
State	:	WA
Zip	:	98271-8151
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9327 4TH ST NE STE 6
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-1630
Country	:	US
Telephone Number	:	425-344-9563
Fax Number	:

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

Provider Enumeration Date	:	04/25/2019
Last Update Date	:	04/25/2019

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