MEDICARE: THEA MONIQUE LAHLUM 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

General Provider Information

NPI Number	:	1689991846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEA MONIQUE LAHLUM CMT

Provider Business Mailing Address
First Line	:	7573 IDAHO AVE N
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-1306
Country	:	US
Telephone Number	:	651-270-8939
Fax Number	:

Provider Business Practice Location Address
First Line	:	7040 LAKELAND AVE N
Second Line	:	SUITE 204
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-5600
Country	:	US
Telephone Number	:	651-270-8939
Fax Number	:

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

Provider Enumeration Date	:	04/28/2010
Last Update Date	:	04/28/2010

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