MEDICARE: TARA NICOLE PINSONNAULT L.M.T

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	12537	CO

General Provider Information

NPI Number	:	1578823183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA NICOLE PINSONNAULT L.M.T

Provider Business Mailing Address
First Line	:	2138 PEPPERWOOD DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-1440
Country	:	US
Telephone Number	:	505-920-8018
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 S CASCADE AVE STE A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-4050
Country	:	US
Telephone Number	:	505-920-8018
Fax Number	:

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

Provider Enumeration Date	:	05/17/2012
Last Update Date	:	05/17/2012

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