Healthcare Provider Details

I. General information

NPI: 1730554999
Provider Name (Legal Business Name): C-TRILOGY COMPREHENSIVE CLINICAL CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 N HIGH ST STE 3
LONGVIEW TX
75601-5377
US

IV. Provider business mailing address

618 N HIGH ST STE 3
LONGVIEW TX
75601-5377
US

V. Phone/Fax

Practice location:
  • Phone: 903-234-8755
  • Fax:
Mailing address:
  • Phone: 903-234-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberAP125290
License Number StateTX

VIII. Authorized Official

Name: TRACY HICKS
Title or Position: OWNER
Credential:
Phone: 903-234-8755