Provider Demographics
NPI:1417275397
Name:TRIVIZ, IRENE MARIE
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:MARIE
Last Name:TRIVIZ
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 1:9112 SABINAL DR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4569
Mailing Address - Country:US
Mailing Address - Phone:719-494-6757
Mailing Address - Fax:505-999-1172
Practice Address - Street 1:2601 WYOMING BLVD NE
Practice Address - Street 2:STE. 101
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1035
Practice Address - Country:US
Practice Address - Phone:505-404-0717
Practice Address - Fax:505-999-1172
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0126211101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health