Healthcare Provider Details

I. General information

NPI: 1649737149
Provider Name (Legal Business Name): LUCAS CHARLES HANERHOFF PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 SE 192ND AVE STE 109
CAMAS WA
98607-7415
US

IV. Provider business mailing address

1905 SE 192ND AVE STE 109
CAMAS WA
98607-7415
US

V. Phone/Fax

Practice location:
  • Phone: 360-210-5440
  • Fax: 360-210-7731
Mailing address:
  • Phone: 360-210-5440
  • Fax: 360-210-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01534
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0020876
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT.PT.70119694-CP
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: