Basic Information
| Provider Information | |||||||||
| NPI: | 1093193534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TREVINO | ||||||||
| FirstName: | JUANITA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 FAIRWAY DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD BCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334411817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888809270 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 PREMIER DRIVE | ||||||||
| Address2: | SUITE #234 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727561222 | ||||||||
| FaxNumber: | 4693740800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235500000X | RBT-15-8217-21224 | TX | Y | Speech, Language and Hearing Service Providers | Specialist/Technologist |
ID Information
| ID | Type | State | Issuer | Description | RBT-15-8217-21224 | 01 | TX | BACB | OTHER |