Provider Demographics
NPI:1568841609
Name:JOHNSON, TREVOR ALLEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 KING STREET
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669
Mailing Address - Country:US
Mailing Address - Phone:315-713-5660
Mailing Address - Fax:315-393-0055
Practice Address - Street 1:39 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-379-4700
Practice Address - Fax:315-713-6512
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209173225100000X
TX1256837225100000X
NY038434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07254337Medicaid