Basic Information
Provider Information | |||||||||
NPI: | 1689841694 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TREVINO | ||||||||
FirstName: | JAYME | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCHILLER | ||||||||
OtherFirstName: | JAYME | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3276 | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477313276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124730181 | ||||||||
FaxNumber: | 8124735822 | ||||||||
Practice Location | |||||||||
Address1: | 7300 E INDIANA ST | ||||||||
Address2: | STE 103 | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477152794 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124018008 | ||||||||
FaxNumber: | 8124018201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2008 | ||||||||
LastUpdateDate: | 02/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34005855A | IN | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 000000961100 | 01 | IN | ANTHEM BCBS | OTHER |