Provider Demographics
NPI:1548886856
Name:TREVINO, MARTHA GINNY
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:GINNY
Last Name:TREVINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:GINNY
Other - Last Name:TREVINO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:439 W HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6392
Mailing Address - Country:US
Mailing Address - Phone:325-939-2650
Mailing Address - Fax:
Practice Address - Street 1:439 W HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6392
Practice Address - Country:US
Practice Address - Phone:325-939-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-20-123885106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-20-123885OtherOTHER