Provider Demographics
NPI:1922306034
Name:LACROUTE, JOSHUA MATTHEW (LAC)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MATTHEW
Last Name:LACROUTE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:JOSHUA
Other - Middle Name:M
Other - Last Name:LIZOTTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:505 NW 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3578
Mailing Address - Country:US
Mailing Address - Phone:503-477-4399
Mailing Address - Fax:503-477-9197
Practice Address - Street 1:505 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3578
Practice Address - Country:US
Practice Address - Phone:503-477-4399
Practice Address - Fax:503-477-9197
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150508171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist