Provider Demographics
NPI:1366640682
Name:TREVINO, JOSE GUADALUPE II (MA, CCC/SLP)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:GUADALUPE
Last Name:TREVINO
Suffix:II
Gender:M
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SANTA ANNA ST
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-4318
Mailing Address - Country:US
Mailing Address - Phone:956-376-7426
Mailing Address - Fax:
Practice Address - Street 1:512 SANTA ANNA ST
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-4318
Practice Address - Country:US
Practice Address - Phone:956-376-7426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-09
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100868235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1889818-01Medicaid