MEDICARE: CORTNEY CARMODY GILLAM 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	MA00017364	WA

General Provider Information

NPI Number	:	1952462194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORTNEY CARMODY GILLAM LMP

Provider Business Mailing Address
First Line	:	501 E MCLOUGHLIN BLVD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98663-3356
Country	:	US
Telephone Number	:	360-696-4580
Fax Number	:	360-735-7626

Provider Business Practice Location Address
First Line	:	501 E MCLOUGHLIN BLVD
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98663-3356
Country	:	US
Telephone Number	:	360-696-4580
Fax Number	:	360-735-7626

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/08/2007

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