Provider Demographics
NPI:1962276329
Name:FARRISS, TREVOR TICE
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:TICE
Last Name:FARRISS
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 1:606 NE VANDA TERRADO
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-5052
Mailing Address - Country:US
Mailing Address - Phone:772-678-2056
Mailing Address - Fax:
Practice Address - Street 1:7108 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician