Provider Demographics
NPI:1609698000
Name:LANDRY, TREVER D (LMT, CPT)
Entity type:Individual
Prefix:
First Name:TREVER
Middle Name:D
Last Name:LANDRY
Suffix:
Gender:M
Credentials:LMT, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2413 E SAINT VRAIN ST APT 101
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4851
Mailing Address - Country:US
Mailing Address - Phone:337-335-8664
Mailing Address - Fax:
Practice Address - Street 1:2413 E SAINT VRAIN ST APT 101
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4851
Practice Address - Country:US
Practice Address - Phone:337-335-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0025836225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist