Healthcare Provider Details

I. General information

NPI: 1679554935
Provider Name (Legal Business Name): AMY JEANETTE TREVINO MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9514 GRAVELLY LAKE DR SW
LAKEWOOD WA
98499-1514
US

IV. Provider business mailing address

9315 GRAVELLY LAKE DR SW SUITE 306
LAKEWOOD WA
98499-1574
US

V. Phone/Fax

Practice location:
  • Phone: 253-983-9395
  • Fax: 253-983-9411
Mailing address:
  • Phone: 253-581-5200
  • Fax: 253-581-5203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1127629
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60318927
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: