Provider Demographics
NPI:1588498869
Name:KERNS, TREVOR JOSEPH DUBOSE (LMBT)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:JOSEPH DUBOSE
Last Name:KERNS
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 WRIGHTSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-3540
Mailing Address - Country:US
Mailing Address - Phone:907-750-0706
Mailing Address - Fax:
Practice Address - Street 1:5102 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7054
Practice Address - Country:US
Practice Address - Phone:907-750-0706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17623225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist