Provider Demographics
NPI:1477626299
Name:TREVINO, AMY LYN (EDS, NCC, LPCC,RPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYN
Last Name:TREVINO
Suffix:
Gender:F
Credentials:EDS, NCC, LPCC,RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 MARBLE AVE NE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2058
Mailing Address - Country:US
Mailing Address - Phone:575-644-9209
Mailing Address - Fax:505-272-3466
Practice Address - Street 1:2600 MARBLE AVE NE BLDG 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:575-644-9209
Practice Address - Fax:505-272-3466
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0116921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68889020Medicaid