Healthcare Provider Details

I. General information

NPI: 1528616935
Provider Name (Legal Business Name): CEREBELLA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16019 VIA SHAVANO
SAN ANTONIO TX
78249-2370
US

IV. Provider business mailing address

16019 VIA SHAVANO
SAN ANTONIO TX
78249-2370
US

V. Phone/Fax

Practice location:
  • Phone: 210-696-9292
  • Fax: 210-690-8815
Mailing address:
  • Phone: 210-696-9292
  • Fax: 210-690-8815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH TREVINO
Title or Position: RECEPTIONIST/ADMIN
Credential:
Phone: 210-696-9292