Provider Demographics
NPI:1083255749
Name:TRAVIS, MARK WILSON
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILSON
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 KNECHTEL WAY NE STE 111
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2834
Mailing Address - Country:US
Mailing Address - Phone:206-472-0535
Mailing Address - Fax:
Practice Address - Street 1:345 KNECHTEL WAY NE STE 111
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2834
Practice Address - Country:US
Practice Address - Phone:206-472-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603312792106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist