Provider Demographics
NPI:1114141009
Name:TRAVIS, EILEEN CAROL (LCSW)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:CAROL
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21704 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3500
Mailing Address - Country:US
Mailing Address - Phone:718-423-7371
Mailing Address - Fax:212-382-6769
Practice Address - Street 1:21704 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3500
Practice Address - Country:US
Practice Address - Phone:718-423-7371
Practice Address - Fax:212-382-6769
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR030727-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical