Provider Demographics
NPI:1942840103
Name:TREVINO-MARTINEZ, GISEL
Entity Type:Individual
Prefix:
First Name:GISEL
Middle Name:
Last Name:TREVINO-MARTINEZ
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 1:1300 E MISSOURI AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2372
Mailing Address - Country:US
Mailing Address - Phone:480-930-0390
Mailing Address - Fax:
Practice Address - Street 1:1300 E MISSOURI AVE STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2372
Practice Address - Country:US
Practice Address - Phone:480-930-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-182701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ001311Medicaid