Healthcare Provider Details

I. General information

NPI: 1588177612
Provider Name (Legal Business Name): TREVOR RICHARDSON PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2017
Last Update Date: 11/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 OLD WARREN RD
MONTICELLO AR
71655-9723
US

IV. Provider business mailing address

1200 OLD WARREN RD
MONTICELLO AR
71655-9723
US

V. Phone/Fax

Practice location:
  • Phone: 870-367-1548
  • Fax: 870-367-1383
Mailing address:
  • Phone: 870-367-1548
  • Fax: 870-367-1383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4413
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: