Provider Demographics
NPI:1689063844
Name:MYERS, SHAUNA (LMT, CMLDT)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:LMT, CMLDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7211 N LEONARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3222
Mailing Address - Country:US
Mailing Address - Phone:916-504-7961
Mailing Address - Fax:
Practice Address - Street 1:2927 NE EVERETT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3248
Practice Address - Country:US
Practice Address - Phone:916-504-7961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20315225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist