Provider Demographics
NPI:1609324433
Name:SHYSHKA, TREVAR
Entity type:Individual
Prefix:
First Name:TREVAR
Middle Name:
Last Name:SHYSHKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 PALM ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-3030
Mailing Address - Country:US
Mailing Address - Phone:408-500-6229
Mailing Address - Fax:408-294-5072
Practice Address - Street 1:810 PALM ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-3030
Practice Address - Country:US
Practice Address - Phone:408-500-6229
Practice Address - Fax:408-294-5072
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA430080AN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA430080ANOtherDHCS CALIFORNIA