Provider Demographics
NPI:1225640352
Name:LAVIGNE, SHAUN
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:LAVIGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 N ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-4424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 PACIFIC AVE # 2
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5231
Practice Address - Country:US
Practice Address - Phone:253-533-9023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61077186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist