MEDICARE: EMMA ELIZABETH WILEY 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	24999	OR

General Provider Information

NPI Number	:	1942760426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA ELIZABETH WILEY LMT

Provider Business Mailing Address
First Line	:	209 W 4TH ST
Second Line	:
City	:	THE DALLES
State	:	OR
Zip	:	97058-1805
Country	:	US
Telephone Number	:	907-750-2835
Fax Number	:

Provider Business Practice Location Address
First Line	:	508 WASHINGTON ST STE 13
Second Line	:
City	:	THE DALLES
State	:	OR
Zip	:	97058-2232
Country	:	US
Telephone Number	:	541-316-0787
Fax Number	:

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

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	06/23/2020

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