MEDICARE: TYNA BOCCAROSSA CMT

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	M01503	MD

General Provider Information

NPI Number	:	1679931265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYNA BOCCAROSSA CMT

Provider Business Mailing Address
First Line	:	12412 CHANNELVIEW DR
Second Line	:
City	:	NEWBURG
State	:	MD
Zip	:	20664-2212
Country	:	US
Telephone Number	:	301-536-3897
Fax Number	:

Provider Business Practice Location Address
First Line	:	12412 CHANNELVIEW DR
Second Line	:
City	:	NEWBURG
State	:	MD
Zip	:	20664-2212
Country	:	US
Telephone Number	:	301-536-3897
Fax Number	:

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

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	02/10/2016

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