MEDICARE: GWENDOLYN KATHLEEN SHATTUCK 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	MA61583202	WA

General Provider Information

NPI Number	:	1457177420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN KATHLEEN SHATTUCK LMT

Provider Business Mailing Address
First Line	:	19519 38TH AVE NE
Second Line	:
City	:	LAKE FOREST PARK
State	:	WA
Zip	:	98155-2609
Country	:	US
Telephone Number	:	206-235-6694
Fax Number	:

Provider Business Practice Location Address
First Line	:	19519 38TH AVE NE
Second Line	:
City	:	LAKE FOREST PARK
State	:	WA
Zip	:	98155-2609
Country	:	US
Telephone Number	:	206-235-6694
Fax Number	:

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

Provider Enumeration Date	:	11/25/2024
Last Update Date	:	11/25/2024

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