Provider Demographics
NPI:1992291819
Name:QUENNEVILLE, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:QUENNEVILLE
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 1:2925 ST. PATRICKS
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9E3G8
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15400 TRENTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2075
Practice Address - Country:US
Practice Address - Phone:734-284-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007953225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist