Provider Demographics
NPI:1689292930
Name:THOMAS-TRUJILLO, CASSIE LYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:LYN
Last Name:THOMAS-TRUJILLO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 531170
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75053-1170
Mailing Address - Country:US
Mailing Address - Phone:972-264-6141
Mailing Address - Fax:
Practice Address - Street 1:2602 S BELT LINE RD
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5344
Practice Address - Country:US
Practice Address - Phone:972-264-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8564235Z00000X
TX118372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANAMedicaid
LANAOtherNA