MEDICARE: LYLE JOHNSON

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	MA6056941	WA

General Provider Information

NPI Number	:	1730548850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYLE JOHNSON

Provider Business Mailing Address
First Line	:	8216 12TH ST SE
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-6663
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8216 12TH ST SE
Second Line	:
City	:	LAKE STEVENS
State	:	WA
Zip	:	98258-6663
Country	:	US
Telephone Number	:	425-879-9620
Fax Number	:

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

Provider Enumeration Date	:	02/17/2016
Last Update Date	:	02/17/2016

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Directions to “ LYLE JOHNSON ” Practice Location

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