Provider Demographics
NPI:1528765930
Name:HYSTAD, SHAWN LEE (LMT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:LEE
Last Name:HYSTAD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 OAK ST BLDG C210
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-8762
Mailing Address - Country:US
Mailing Address - Phone:406-587-8446
Mailing Address - Fax:406-587-0898
Practice Address - Street 1:1001 OAK ST BLDG C210
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-8762
Practice Address - Country:US
Practice Address - Phone:406-587-8446
Practice Address - Fax:406-587-0898
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-24634225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0900719884128OtherDRIVER'S LICENSE