Healthcare Provider Details

I. General information

NPI: 1740938422
Provider Name (Legal Business Name): TREJA MCCLISH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2022
Last Update Date: 03/12/2022
Certification Date: 03/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 LA PLZ STE 100
COTATI CA
94931-5216
US

IV. Provider business mailing address

1818 LA PLZ STE 100
COTATI CA
94931-5216
US

V. Phone/Fax

Practice location:
  • Phone: 707-772-6256
  • Fax:
Mailing address:
  • Phone: 707-772-6256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: