Provider Demographics
NPI:1952686966
Name:THOMAS, TREVOR S SR
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:S
Last Name:THOMAS
Suffix:SR
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 1:515 N PARK AVE STE 201B
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-3653
Mailing Address - Country:US
Mailing Address - Phone:407-703-5959
Mailing Address - Fax:
Practice Address - Street 1:515 N PARK AVE STE 201B
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-3653
Practice Address - Country:US
Practice Address - Phone:407-703-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003564600Medicaid