Basic Information
| Provider Information | |||||||||
| NPI: | 1669551750 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TREVINO | ||||||||
| FirstName: | LISSA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 CALLE AMANECER STE 320 | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926734222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493666785 | ||||||||
| FaxNumber: | 9493666470 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 CALLE AMANECER | ||||||||
| Address2: | STE 320 | ||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926736278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493666785 | ||||||||
| FaxNumber: | 9493666470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | PT21353 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.