Provider Demographics
NPI:1740938422
Name:MCCLISH, TREJA
Entity type:Individual
Prefix:
First Name:TREJA
Middle Name:
Last Name:MCCLISH
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 1:1818 LA PLZ STE 100
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-5216
Mailing Address - Country:US
Mailing Address - Phone:707-772-6256
Mailing Address - Fax:
Practice Address - Street 1:1818 LA PLZ STE 100
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-5216
Practice Address - Country:US
Practice Address - Phone:707-772-6256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner