Provider Demographics
NPI:1528567641
Name:TREVINO, ROSEANNE
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:
Last Name:TREVINO
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 1:9064 LANCASTER LN
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-7590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-7607
Practice Address - Country:US
Practice Address - Phone:630-269-2886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-04
Last Update Date:2018-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0200481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical