Provider Demographics
NPI:1700449493
Name:SKINNER, WILLIAM SHANE (LMT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SHANE
Last Name:SKINNER
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 1:6450 TACOMA MALL BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-6796
Mailing Address - Country:US
Mailing Address - Phone:800-689-1254
Mailing Address - Fax:
Practice Address - Street 1:1200 EXECUTIVE PKWY STE 230
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2365
Practice Address - Country:US
Practice Address - Phone:541-636-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23806225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist