Provider Demographics
NPI:1821283177
Name:AUTUMN VIEW ALLIANCE, LLC
Entity Type:Organization
Organization Name:AUTUMN VIEW ALLIANCE, LLC
Other - Org Name:AUTUMN VIEW ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:210-250-1298
Mailing Address - Street 1:1136 E. KINGSBURY ST.
Mailing Address - Street 2:PMB 184
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-2148
Mailing Address - Country:US
Mailing Address - Phone:210-250-1298
Mailing Address - Fax:
Practice Address - Street 1:261 TURTLE LN
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-3142
Practice Address - Country:US
Practice Address - Phone:210-250-1298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2012-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11530103TB0200X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166851903Medicaid
TX166851902Medicaid
TXTXB101283OtherMEDICARE GROUP
TX611706Medicare UPIN