Provider Demographics
NPI:1942894290
Name:TREVINO, ETHAN W (LMT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:W
Last Name:TREVINO
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 1:64770 BIG BUCK DR
Mailing Address - Street 2:
Mailing Address - City:DEER ISLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97054-9418
Mailing Address - Country:US
Mailing Address - Phone:801-686-3612
Mailing Address - Fax:
Practice Address - Street 1:5253 NE SANDY BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2562
Practice Address - Country:US
Practice Address - Phone:503-893-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26242225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist