Healthcare Provider Details

I. General information

NPI: 1659322733
Provider Name (Legal Business Name): TRINITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 S. BROADWAY, SUITE 102
TYLER TN
75701
US

IV. Provider business mailing address

PO BOX 5500
TYLER TX
75712-5500
US

V. Phone/Fax

Practice location:
  • Phone: 903-593-1786
  • Fax:
Mailing address:
  • Phone: 903-324-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY ANN HARRISON
Title or Position: PHYSICIAN CLINIC SUPPORT COORDINATO
Credential: CPC, CMC
Phone: 903-510-1113