Provider Demographics
NPI:1609539790
Name:TREVINO, CLARYSSA RAE (LPC)
Entity Type:Individual
Prefix:
First Name:CLARYSSA
Middle Name:RAE
Last Name:TREVINO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:CLARYSSA
Other - Middle Name:RAE
Other - Last Name:MANCILLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:24200 SOUTHWEST FWY STE 402-127
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-5984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2626 S LOOP W STE 318
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2641
Practice Address - Country:US
Practice Address - Phone:832-795-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73360101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health