Healthcare Provider Details

I. General information

NPI: 1376993907
Provider Name (Legal Business Name): JUSTIN WYCOFF LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6030 SE DIVISION ST
PORTLAND OR
97206-1346
US

IV. Provider business mailing address

711 SE 11TH AVE APT 3
PORTLAND OR
97214-2451
US

V. Phone/Fax

Practice location:
  • Phone: 503-772-1215
  • Fax:
Mailing address:
  • Phone: 707-321-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number22208
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: