MEDICARE: SUSAN WENDELL VAN HORNE 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	MA00003538	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0288162	OTHER	WA	L & I
2	0288172	OTHER	WA	L & I

General Provider Information

NPI Number	:	1811078439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN WENDELL VAN HORNE LMP

Provider Business Mailing Address
First Line	:	2445 NW 57TH ST
Second Line	:	709
City	:	SEATTLE
State	:	WA
Zip	:	98107-5330
Country	:	US
Telephone Number	:	206-778-6167
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 NW 57TH ST
Second Line	:	709
City	:	SEATTLE
State	:	WA
Zip	:	98107-5330
Country	:	US
Telephone Number	:	206-778-6167
Fax Number	:

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

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	01/19/2016

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