Provider Demographics
NPI:1104675784
Name:BOE, TREVOR DANIEL (LMT)
Entity type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:DANIEL
Last Name:BOE
Suffix:
Gender:M
Credentials:LMT
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 35
Mailing Address - Street 2:
Mailing Address - City:SEELEY LAKE
Mailing Address - State:MT
Mailing Address - Zip Code:59868-0035
Mailing Address - Country:US
Mailing Address - Phone:406-303-0220
Mailing Address - Fax:
Practice Address - Street 1:2409 DEARBORN AVE STE E
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7748
Practice Address - Country:US
Practice Address - Phone:406-543-7860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-24866225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist