Provider Demographics
NPI:1982681078
Name:STEVENSON, TREVOR JACK
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:JACK
Last Name:STEVENSON
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 1:9720 S 1300 E
Mailing Address - Street 2:#W200
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3712
Mailing Address - Country:US
Mailing Address - Phone:801-572-0690
Mailing Address - Fax:
Practice Address - Street 1:9720 S 1300 E
Practice Address - Street 2:#W200
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3712
Practice Address - Country:US
Practice Address - Phone:801-572-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5107863-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP58447Medicare UPIN