MEDICARE: MS. SALLY DENISE GOSSETT NTS

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	581	NM

General Provider Information

NPI Number	:	1780737338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SALLY DENISE GOSSETT NTS

Provider Business Mailing Address
First Line	:	PO BOX 37277
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87176-7277
Country	:	US
Telephone Number	:	505-610-7784
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 GEORGIA ST NE
Second Line	:	SUITE A-4
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-1359
Country	:	US
Telephone Number	:	595-610-7784
Fax Number	:

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	03/26/2012

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