MEDICARE: MICHAEL SPENCER KUPERSTEIN MASSAGE THERAPIST

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	60897071	WA

General Provider Information

NPI Number	:	1649938242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL SPENCER KUPERSTEIN MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	4248 LAKE WASHINGTON BLVD SE
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98006-1110
Country	:	US
Telephone Number	:	845-444-0148
Fax Number	:

Provider Business Practice Location Address
First Line	:	4248 LAKE WASHINGTON BLVD SE
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98006-1110
Country	:	US
Telephone Number	:	845-444-0148
Fax Number	:

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

Provider Enumeration Date	:	12/01/2021
Last Update Date	:	12/01/2021

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