MEDICARE: DEBORAH G POWELL NCTMB

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	511654-06	OTHER	ID	NATIONAL CERTIFICATION BOARD FOR THERAPEUTIC MASSAGE & BODYWORK
2	MX 070017	OTHER	ID	BOISE CITY MASSAGE EXEMPT LICENSE

General Provider Information

NPI Number	:	1881830586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH G POWELL NCTMB

Provider Business Mailing Address
First Line	:	9448D W FAIRVIEW AVE # D
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8101
Country	:	US
Telephone Number	:	208-629-2006
Fax Number	:

Provider Business Practice Location Address
First Line	:	9448D W FAIRVIEW AVE # D
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83704-8101
Country	:	US
Telephone Number	:	208-629-2006
Fax Number	:

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

Provider Enumeration Date	:	12/30/2008
Last Update Date	:	12/30/2008

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