MEDICARE: MRS. MONIQUE T WIEDRICH LMP

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	MA00017965	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0200946	OTHER	WA	DEPT. OF L&I

General Provider Information

NPI Number	:	1336241090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MONIQUE T WIEDRICH LMP

Provider Business Mailing Address
First Line	:	2001 36TH LN NE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98506-2559
Country	:	US
Telephone Number	:	360-705-9692
Fax Number	:

Provider Business Practice Location Address
First Line	:	3948 CLEVELAND AVE SE STE A
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98501-4023
Country	:	US
Telephone Number	:	360-570-9580
Fax Number	:	360-570-9583

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

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2007

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