Healthcare Provider Details

I. General information

NPI: 1790602704
Provider Name (Legal Business Name): HOLLY RENEE TREVOR CPRC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42590 STEPNITZ DR
CLINTON TOWNSHIP MI
48036-3161
US

IV. Provider business mailing address

42590 STEPNITZ DR
CLINTON TOWNSHIP MI
48036-3161
US

V. Phone/Fax

Practice location:
  • Phone: 586-954-1838
  • Fax: 586-649-2620
Mailing address:
  • Phone: 586-954-1838
  • Fax: 586-649-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberT616313734861
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: