=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154822880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTHA JEAN TREVINO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2018
-----------------------------------------------------
Last Update Date | 02/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1156 W MONTE CRISTO RD
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78541-4541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-383-1243
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 TAHITI DR APT 3
-----------------------------------------------------
City | EDINBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78541-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-212-7900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | 35275
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------