MEDICARE: MR. DOUGLAS ALAN LEESE 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	MA00016504	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	165116	OTHER	WA	LABOR AND INDUSTRIES

General Provider Information

NPI Number	:	1588867246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOUGLAS ALAN LEESE LMT

Provider Business Mailing Address
First Line	:	PO BOX 4303
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-4303
Country	:	US
Telephone Number	:	509-429-8051
Fax Number	:

Provider Business Practice Location Address
First Line	:	616 IRONWOOD ST
Second Line	:
City	:	OMAK
State	:	WA
Zip	:	98841-9545
Country	:	US
Telephone Number	:	509-429-8051
Fax Number	:

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

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	02/14/2019

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