Provider Demographics
NPI:1447893656
Name:TREVINO, ANITA DIAZ
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:DIAZ
Last Name:TREVINO
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 1:1300 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79102-1611
Mailing Address - Country:US
Mailing Address - Phone:806-584-7578
Mailing Address - Fax:
Practice Address - Street 1:3323 BELL ST STE E
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-5031
Practice Address - Country:US
Practice Address - Phone:806-626-3876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT130855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty