MEDICARE: BETTY BERKHOUSEN 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	MA00017094	WA

General Provider Information

NPI Number	:	1366820987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETTY BERKHOUSEN LMP

Provider Business Mailing Address
First Line	:	PO BOX 649
Second Line	:
City	:	NEWPORT
State	:	WA
Zip	:	99156-0649
Country	:	US
Telephone Number	:	509-671-2044
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 W 1ST ST
Second Line	:
City	:	NEWPORT
State	:	WA
Zip	:	99156-9035
Country	:	US
Telephone Number	:	509-671-2044
Fax Number	:

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

Provider Enumeration Date	:	05/14/2015
Last Update Date	:	05/14/2015

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