Provider Demographics
NPI:1598714867
Name:DAVIDSON, TREVOR (PT, DPT, OCS, MTC)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:PT, DPT, OCS, MTC
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:TREVOR
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3902 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3141
Mailing Address - Country:US
Mailing Address - Phone:479-364-0223
Mailing Address - Fax:479-364-0397
Practice Address - Street 1:3902 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3141
Practice Address - Country:US
Practice Address - Phone:479-364-0223
Practice Address - Fax:479-364-0397
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2893225100000X
ARPT 2893225100000X
GAPT009386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159990721Medicaid
AR71085780150OtherQUALCHOICE
AR445934001OtherPALMETTO GI DME
AR662725OtherHEALTHLINK
MO791200OtherBCBS-ANTHEM
MOMA4370090OtherMEDICARE PTAN
AR159990721Medicaid
AR71085780150OtherQUALCHOICE