Provider Demographics
NPI:1427531656
Name:TREVINO, SUSANNAH C (MT-BC)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:C
Last Name:TREVINO
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:SUSANNAH
Other - Middle Name:C
Other - Last Name:GAFKJEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT-BC
Mailing Address - Street 1:860 MILL ST N STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-2213
Mailing Address - Country:US
Mailing Address - Phone:608-799-4860
Mailing Address - Fax:414-377-3353
Practice Address - Street 1:860 MILL ST N STE 2
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-2213
Practice Address - Country:US
Practice Address - Phone:608-799-4860
Practice Address - Fax:414-377-3353
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11330225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist