Provider Demographics
NPI:1770937740
Name:LEGOUEST, ULRIC SHAWN (LMT)
Entity type:Individual
Prefix:
First Name:ULRIC
Middle Name:SHAWN
Last Name:LEGOUEST
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 1:12530 SE MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1241
Mailing Address - Country:US
Mailing Address - Phone:503-314-1722
Mailing Address - Fax:
Practice Address - Street 1:22400 SE STARK ST # 105
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2656
Practice Address - Country:US
Practice Address - Phone:503-907-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21816225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist