Provider Demographics
NPI:1851428957
Name:TREVINO, MARY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:TREVINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 TURTLE LN
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-3142
Mailing Address - Country:US
Mailing Address - Phone:210-250-1298
Mailing Address - Fax:830-433-4790
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:830-433-4790
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11530103TH0100X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166851902Medicaid
TX166851902Medicaid