Healthcare Provider Details

I. General information

NPI: 1396125407
Provider Name (Legal Business Name): TREVOR MACKIN PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NAPA VALLEJO HWY
NAPA CA
94558-6234
US

IV. Provider business mailing address

2100 NAPA VALLEJO HWY
NAPA CA
94558-6234
US

V. Phone/Fax

Practice location:
  • Phone: 707-253-5660
  • Fax:
Mailing address:
  • Phone: 707-253-5660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY26551
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: