MEDICARE: SUSAN LYELL 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	MA60400309	WA

General Provider Information

NPI Number	:	1346639424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LYELL LMP

Provider Business Mailing Address
First Line	:	951 4TH ST
Second Line	:
City	:	MUKILTEO
State	:	WA
Zip	:	98275-1629
Country	:	US
Telephone Number	:	206-595-7026
Fax Number	:

Provider Business Practice Location Address
First Line	:	8490 MUKILTEO SPEEDWAY
Second Line	:
City	:	MUKILTEO
State	:	WA
Zip	:	98275-3206
Country	:	US
Telephone Number	:	206-595-7026
Fax Number	:

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

Provider Enumeration Date	:	01/13/2015
Last Update Date	:	01/13/2015

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