MEDICARE: LEAH MARIE IVANOFF LMP

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	MA00020112	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA00020112	OTHER	WA	WASHINGTON STATE DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1598099012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH MARIE IVANOFF LMP

Provider Business Mailing Address
First Line	:	3703 CALIFORNIA AVE SW
Second Line	:	SUITE A
City	:	SEATTLE
State	:	WA
Zip	:	98116-3771
Country	:	US
Telephone Number	:	206-937-3965
Fax Number	:	206-937-4695

Provider Business Practice Location Address
First Line	:	3703 CALIFORNIA AVE SW
Second Line	:	SUITE A
City	:	SEATTLE
State	:	WA
Zip	:	98116-3771
Country	:	US
Telephone Number	:	206-937-3965
Fax Number	:	206-937-4695

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

Provider Enumeration Date	:	09/30/2009
Last Update Date	:	09/30/2009

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Directions to “ LEAH MARIE IVANOFF LMP” Practice Location

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