Provider Demographics
NPI:1033860929
Name:TREVARTHAN, ROXANNE
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:TREVARTHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1183 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01603-2012
Mailing Address - Country:US
Mailing Address - Phone:508-859-9178
Mailing Address - Fax:
Practice Address - Street 1:1183 MAIN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2012
Practice Address - Country:US
Practice Address - Phone:508-859-9178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2276512363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health