MEDICARE: LILLIAN NYSTROM THARP M.ED.

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1538675319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLIAN NYSTROM THARP M.ED.

Provider Business Mailing Address
First Line	:	4523 S LUCILE ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-2420
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4523 S LUCILE ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98118-2420
Country	:	US
Telephone Number	:	651-491-6721
Fax Number	:

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

Provider Enumeration Date	:	12/15/2017
Last Update Date	:	12/15/2017

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