Provider Demographics
NPI:1851078315
Name:CLEWIS, TRICILICA
Entity Type:Individual
Prefix:
First Name:TRICILICA
Middle Name:
Last Name:CLEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 LAS COLINAS BLVD E APT 254
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-6270
Mailing Address - Country:US
Mailing Address - Phone:469-586-7643
Mailing Address - Fax:
Practice Address - Street 1:367 LAS COLINAS BLVD E APT 254
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-6270
Practice Address - Country:US
Practice Address - Phone:469-586-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty