MEDICARE: KATHLEEN WILSON LMT

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	MT4503	ME

General Provider Information

NPI Number	:	1881992816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN WILSON LMT

Provider Business Mailing Address
First Line	:	362 RYERSON HILL RD
Second Line	:
City	:	SOUTH PARIS
State	:	ME
Zip	:	04281-6205
Country	:	US
Telephone Number	:	207-595-1259
Fax Number	:

Provider Business Practice Location Address
First Line	:	362 RYERSON HILL RD
Second Line	:
City	:	SOUTH PARIS
State	:	ME
Zip	:	04281-6205
Country	:	US
Telephone Number	:	207-595-1259
Fax Number	:

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

Provider Enumeration Date	:	02/28/2011
Last Update Date	:	02/28/2011

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