Provider Demographics
NPI:1710262027
Name:TREVINO, THALIA (OTA)
Entity Type:Individual
Prefix:MS
First Name:THALIA
Middle Name:
Last Name:TREVINO
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6942 SAHARASTONE DR
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3473
Mailing Address - Country:US
Mailing Address - Phone:210-788-3289
Mailing Address - Fax:
Practice Address - Street 1:15911 NACOGDOCHES RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-1107
Practice Address - Country:US
Practice Address - Phone:210-599-7733
Practice Address - Fax:210-599-3105
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209787224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant