Provider Demographics
NPI:1992287478
Name:LOVE, TREVOR WAYNE (PTA)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:WAYNE
Last Name:LOVE
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 1:2211 E CLAIBORNE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3823
Mailing Address - Country:US
Mailing Address - Phone:417-569-9808
Mailing Address - Fax:
Practice Address - Street 1:2211 E CLAIBORNE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3823
Practice Address - Country:US
Practice Address - Phone:417-569-9808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018026147225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty