Provider Demographics
NPI:1679554935
Name:TREVINO, AMY JEANETTE (MPT)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:JEANETTE
Last Name:TREVINO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9315 GRAVELLY LAKE DR SW
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1574
Mailing Address - Country:US
Mailing Address - Phone:253-581-5200
Mailing Address - Fax:253-581-5203
Practice Address - Street 1:9514 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1514
Practice Address - Country:US
Practice Address - Phone:253-983-9395
Practice Address - Fax:253-983-9411
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11276292251X0800X
WAPT60318927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0319928OtherWA L&I PROVIDER NUMBER
WA0319928OtherWA L&I PROVIDER NUMBER