MEDICARE: MARY LYNN GRIZZELL LMP

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	MA60095108	WA

General Provider Information

NPI Number	:	1750606794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LYNN GRIZZELL LMP

Provider Business Mailing Address
First Line	:	2928 DETOUR RD
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-7278
Country	:	US
Telephone Number	:	509-386-5325
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 S COLLEGE AVE STE 101
Second Line	:
City	:	COLLEGE PLACE
State	:	WA
Zip	:	99324-1193
Country	:	US
Telephone Number	:	509-527-2425
Fax Number	:	509-527-2426

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

Provider Enumeration Date	:	04/01/2010
Last Update Date	:	04/01/2010

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