Provider Demographics
NPI:1881200541
Name:MCDANIEL, TREVON TAMAR
Entity Type:Individual
Prefix:MR
First Name:TREVON
Middle Name:TAMAR
Last Name:MCDANIEL
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 1:398 FORD CIR
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25428-4406
Mailing Address - Country:US
Mailing Address - Phone:304-820-9413
Mailing Address - Fax:
Practice Address - Street 1:165 THOMAS JOHNSON DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4742
Practice Address - Country:US
Practice Address - Phone:301-694-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002673225200000X
MDA5391225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant