Provider Demographics
NPI:1598484651
Name:PAVEGLIO, TRENT THOMAS
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:THOMAS
Last Name:PAVEGLIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9146 NATURE MEADOWS DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7484
Mailing Address - Country:US
Mailing Address - Phone:810-931-0223
Mailing Address - Fax:
Practice Address - Street 1:521 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1376
Practice Address - Country:US
Practice Address - Phone:616-866-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI501013035225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist