Provider Demographics
NPI:1548760796
Name:VANLEEUWEN, ERIC MARTIN (LMT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:MARTIN
Last Name:VANLEEUWEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 SE TENINO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6539
Mailing Address - Country:US
Mailing Address - Phone:415-609-4343
Mailing Address - Fax:
Practice Address - Street 1:2403 SE MONROE ST STE B
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7646
Practice Address - Country:US
Practice Address - Phone:503-303-4078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23759225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist