Provider Demographics
NPI:1407848419
Name:SWOVERLAND, TRENTON R (PT)
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:R
Last Name:SWOVERLAND
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9602 COLDWATER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2095
Mailing Address - Country:US
Mailing Address - Phone:260-489-9887
Mailing Address - Fax:260-489-9121
Practice Address - Street 1:9602 COLDWATER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2095
Practice Address - Country:US
Practice Address - Phone:260-489-9887
Practice Address - Fax:260-489-9121
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200374570AMedicaid
IN200374570AMedicaid
IN183320BMedicare ID - Type Unspecified