Provider Demographics
NPI:1700402666
Name:ERAZO-TRIVINO, AUDREY (MA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:ERAZO-TRIVINO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E STEVENS AVE STE LL5
Mailing Address - Street 2:
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1286
Mailing Address - Country:US
Mailing Address - Phone:914-522-5602
Mailing Address - Fax:
Practice Address - Street 1:529 COURTLANDT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5007
Practice Address - Country:US
Practice Address - Phone:914-522-5602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73935103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY73935OtherNEW YORK STATE EDUCATION DEPARTMENT