Provider Demographics
NPI:1477387546
Name:TREVINO, MIRANDA HOPE
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:HOPE
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:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:TX
Mailing Address - Zip Code:78069-0024
Mailing Address - Country:US
Mailing Address - Phone:210-243-4760
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 24
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:TX
Practice Address - Zip Code:78069-0024
Practice Address - Country:US
Practice Address - Phone:210-243-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer