Provider Demographics
NPI:1205549458
Name:TREVINO, LISA (MA,CCC-SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TREVINO
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14546 BROOK HOLLOW BLVD # 337
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-3810
Mailing Address - Country:US
Mailing Address - Phone:210-202-6333
Mailing Address - Fax:
Practice Address - Street 1:901 NE 6TH ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TX
Practice Address - Zip Code:78957-1669
Practice Address - Country:US
Practice Address - Phone:512-237-2487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist