Provider Demographics
NPI:1508522681
Name:TREVETT, LARA (PT, DPT, PCS)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:TREVETT
Suffix:
Gender:F
Credentials:PT, DPT, PCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2952 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8164
Mailing Address - Country:US
Mailing Address - Phone:682-465-2537
Mailing Address - Fax:
Practice Address - Street 1:1051 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3100
Practice Address - Country:US
Practice Address - Phone:843-654-9694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC109612251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty