MEDICARE: MS. GEORGETTE ANN TREZVANT MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	ISW01704	RI

General Provider Information

NPI Number	:	1154315943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GEORGETTE ANN TREZVANT MSW

Provider Business Mailing Address
First Line	:	1100 WILFORD HALL LOOP BLDG 4554
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78236-5638
Country	:	US
Telephone Number	:	210-292-6654
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 WILFORD HALL LOOP BLDG 4554
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78236-5638
Country	:	US
Telephone Number	:	210-292-6654
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	12/09/2020

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