MEDICARE: BRIANNE PUCKETT 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	20203	OR

General Provider Information

NPI Number	:	1710381389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIANNE PUCKETT LMT

Provider Business Mailing Address
First Line	:	5035 NE ELAM YOUNG PKWY
Second Line	:	SUITE 500
City	:	HILLSBORO
State	:	OR
Zip	:	97124-6425
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5035 NE ELAM YOUNG PKWY
Second Line	:	SUITE 500
City	:	HILLSBORO
State	:	OR
Zip	:	97124-6425
Country	:	US
Telephone Number	:	503-693-1151
Fax Number	:	503-693-1153

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

Provider Enumeration Date	:	10/10/2014
Last Update Date	:	01/03/2017

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