Provider Demographics
NPI:1073660973
Name:TRAVISS, PATRICK A (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:A
Last Name:TRAVISS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 SAN RAMON WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3967
Mailing Address - Country:US
Mailing Address - Phone:707-539-6809
Mailing Address - Fax:707-539-6809
Practice Address - Street 1:2455 BENNETT VALLEY RD
Practice Address - Street 2:SUITE 208B
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5663
Practice Address - Country:US
Practice Address - Phone:707-526-2595
Practice Address - Fax:707-539-6809
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 40351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ77769ZMedicare PIN