Provider Demographics
NPI:1962469247
Name:TREVINO, HEDY M (LADAC)
Entity Type:Individual
Prefix:MS
First Name:HEDY
Middle Name:M
Last Name:TREVINO
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:OCATE
Mailing Address - State:NM
Mailing Address - Zip Code:87734
Mailing Address - Country:US
Mailing Address - Phone:505-429-2108
Mailing Address - Fax:
Practice Address - Street 1:3001 HOT SPRINGS BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4175
Practice Address - Country:US
Practice Address - Phone:505-425-6786
Practice Address - Fax:505-425-6786
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0087641101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4888324Medicaid