Provider Demographics
NPI:1871128355
Name:TREVINO, JOEL (PTA)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:TREVINO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:349 12TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5712
Practice Address - Country:US
Practice Address - Phone:801-942-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7402239-2402OtherPTA LICENSE