Provider Demographics
NPI:1669551750
Name:TREVINO, LISSA A (PT)
Entity type:Individual
Prefix:MRS
First Name:LISSA
Middle Name:A
Last Name:TREVINO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CALLE AMANECER STE 320
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-4222
Mailing Address - Country:US
Mailing Address - Phone:949-366-6785
Mailing Address - Fax:949-366-6470
Practice Address - Street 1:901 CALLE AMANECER
Practice Address - Street 2:STE 320
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6278
Practice Address - Country:US
Practice Address - Phone:949-366-6785
Practice Address - Fax:949-366-6470
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21353225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15153Medicare ID - Type UnspecifiedGROUP #