Organization
AUTUMN VIEW ALLIANCE, LLC
Active
Other names
Autumn View Alliance
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARY L. TREVINO PH.D. (PSYCHOLOGIST/MANAGER)
(210) 250-1298
Entity
Organization
Contact information
Practice address
261 TURTLE LN, SEGUIN, TX 78155-3142
(210) 250-1298
Mailing address
1136 E. KINGSBURY ST., PMB 184, SEGUIN, TX 78155-2148
(210) 250-1298
Taxonomy
Speciality
Code
Description
License number
State
103TB0200X
Cognitive & Behavioral Psychologist
Primary
11530
TX
103TC0700X
Clinical Psychologist
11530
TX
103TH0100X
Health Service Psychologist
11530
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
166851902
—
TX
05
—
166851903
—
TX
01
—
TXB101283
MEDICARE GROUP
TX
Enumeration date
09/10/2007
Last updated
11/03/2012
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