Provider Demographics
NPI:1093179368
Name:TERRY, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:TERRY
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 1:7473 W LAKE MEAD BLVD
Mailing Address - Street 2:SUITE #205
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0265
Mailing Address - Country:US
Mailing Address - Phone:702-562-1288
Mailing Address - Fax:702-562-8162
Practice Address - Street 1:7473 W LAKE MEAD BLVD
Practice Address - Street 2:SUITE #205
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0265
Practice Address - Country:US
Practice Address - Phone:702-562-1288
Practice Address - Fax:702-562-8162
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst