Provider Demographics
NPI:1558526913
Name:ENSIGN, STEPHEN T (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:ENSIGN
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 1:1911 MOUNTAIN VIEW LANE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-2382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1911 MOUNTAIN VIEW LANE
Practice Address - Street 2:SUITE 200
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2382
Practice Address - Country:US
Practice Address - Phone:503-357-2826
Practice Address - Fax:503-357-4831
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4188174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist