Provider Demographics
NPI:1982711933
Name:JOHNSON, TREVOR (PT)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11221 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 SOLAREX COURT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703
Practice Address - Country:US
Practice Address - Phone:301-663-7930
Practice Address - Fax:301-663-7931
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21546225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist