Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
Y | 1041C0700X | Clinical Social Worker | 0904013297 | VA |
NPI | 1003122193 |
---|---|
Provider Name | Kelly Patino Trejo |
First Address | Norfolk, VA 23507-1971 |
Second Address | Norfolk, VA 23507-1910 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2010 |
Last Update Date | 26/01/2022 |