MEDICARE: GLENDA ENAGONIO LMT, RCST, SEP

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	M02869	MD

General Provider Information

NPI Number	:	1811556996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENDA ENAGONIO LMT, RCST, SEP

Provider Business Mailing Address
First Line	:	10605 CONCORD ST STE 410
Second Line	:
City	:	KENSINGTON
State	:	MD
Zip	:	20895-2519
Country	:	US
Telephone Number	:	240-426-2416
Fax Number	:

Provider Business Practice Location Address
First Line	:	10605 CONCORD ST STE 410
Second Line	:
City	:	KENSINGTON
State	:	MD
Zip	:	20895-2519
Country	:	US
Telephone Number	:	240-426-2416
Fax Number	:

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

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	06/11/2019

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