Provider Demographics
NPI:1194558999
Name:PROSISE, TREVAWN
Entity type:Individual
Prefix:
First Name:TREVAWN
Middle Name:
Last Name:PROSISE
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 1:311 KARL LINN DR. #413
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225
Mailing Address - Country:US
Mailing Address - Phone:703-459-8158
Mailing Address - Fax:
Practice Address - Street 1:7807 ELM BIRCH LN
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-5603
Practice Address - Country:US
Practice Address - Phone:703-459-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management