Provider Demographics
NPI:1902679384
Name:HENNESSY, TRYSTAN MICAH
Entity Type:Individual
Prefix:
First Name:TRYSTAN
Middle Name:MICAH
Last Name:HENNESSY
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 1:5509 50TH ST APT 1205
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-1624
Mailing Address - Country:US
Mailing Address - Phone:575-309-1168
Mailing Address - Fax:
Practice Address - Street 1:6502 SLIDE RD STE 204
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-1311
Practice Address - Country:US
Practice Address - Phone:806-686-0429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant