Provider Demographics
NPI:1326112517
Name:TRELLO, DOLORES S (PSYD)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:S
Last Name:TRELLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3207 MATHERS ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711
Mailing Address - Country:US
Mailing Address - Phone:217-793-3668
Mailing Address - Fax:217-793-9483
Practice Address - Street 1:3207 MATHERS ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711
Practice Address - Country:US
Practice Address - Phone:217-793-3668
Practice Address - Fax:217-793-9483
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8419943OtherBC/BS
IL361600Medicare ID - Type Unspecified