MEDICARE: HEART'S DESIRE CRANIOSACRAL AND MASSAGE THERAPY

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	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1497321186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART'S DESIRE CRANIOSACRAL AND MASSAGE THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 65595
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98665-0020
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 WASHINGTON ST STE 5
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98660-3138
Country	:	US
Telephone Number	:	360-524-2772
Fax Number	:

Authorized Official
Title or Position	:	LMT
Name	:	AMY WYENBERG
Credential	:
Telephone Number	:	360-524-2772

Provider Enumeration Date	:	06/02/2021
Last Update Date	:	06/02/2021

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