Provider Demographics
NPI:1154775799
Name:KOOKEN-HOVER, SHANE (LMT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:KOOKEN-HOVER
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 1:11795 SW TUALATIN RD
Mailing Address - Street 2:#67
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7444
Mailing Address - Country:US
Mailing Address - Phone:503-422-1865
Mailing Address - Fax:
Practice Address - Street 1:12700 SW NORTH DAKOTA ST
Practice Address - Street 2:STE 180
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-0802
Practice Address - Country:US
Practice Address - Phone:503-716-8281
Practice Address - Fax:503-716-8783
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19795225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist