MEDICARE: TREVOR COLIN STEPHENSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1417544099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TREVOR COLIN STEPHENSON

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15630 OLD COLUMBIA PIKE STE F
Second Line	:
City	:	BURTONSVILLE
State	:	MD
Zip	:	20866-1617
Country	:	US
Telephone Number	:	240-559-5270
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2020
Last Update Date	:	12/29/2020

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