Provider Demographics
NPI:1649684119
Name:TREJO, YESENIA RUBY (LMSW)
Entity type:Individual
Prefix:
First Name:YESENIA
Middle Name:RUBY
Last Name:TREJO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3736
Mailing Address - Country:US
Mailing Address - Phone:208-520-6476
Mailing Address - Fax:
Practice Address - Street 1:118 E. LANDER ST.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-234-2094
Practice Address - Fax:208-234-2637
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-33667104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker