Healthcare Provider Details

I. General information

NPI: 1164095907
Provider Name (Legal Business Name): TREVOR JON VANASSELT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29665 WILLIAM K SMITH DR
NEW HUDSON MI
48165-8580
US

IV. Provider business mailing address

12881 TEN MILE RD
SOUTH LYON MI
48178-9187
US

V. Phone/Fax

Practice location:
  • Phone: 517-420-8266
  • Fax:
Mailing address:
  • Phone: 248-982-3426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: