Healthcare Provider Details

I. General information

NPI: 1710467816
Provider Name (Legal Business Name): TREVOR FARM PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W HARRISON ST STE 160
SEATTLE WA
98119-4116
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD STE 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 206-352-0105
  • Fax: 206-352-0106
Mailing address:
  • Phone: 503-443-6156
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60852111
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: