Provider Demographics
NPI:1982104634
Name:NELSON, TREVOR L (DPT, PT)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2469
Mailing Address - Country:US
Mailing Address - Phone:231-487-7486
Mailing Address - Fax:231-487-7791
Practice Address - Street 1:416 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2212
Practice Address - Country:US
Practice Address - Phone:231-487-7486
Practice Address - Fax:231-487-7791
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501615958261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy