Provider Demographics
NPI:1386175636
Name:POLIVKA, TREVOR MITCHELL
Entity type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:MITCHELL
Last Name:POLIVKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68531-8924
Mailing Address - Country:US
Mailing Address - Phone:402-937-2662
Mailing Address - Fax:
Practice Address - Street 1:8100 N 1ST ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68531-8924
Practice Address - Country:US
Practice Address - Phone:402-937-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEH134963902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer