Provider Demographics
NPI:1114202074
Name:TRAVIS, BRAD (MSCADC)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:MSCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60434-0153
Mailing Address - Country:US
Mailing Address - Phone:815-690-0213
Mailing Address - Fax:815-846-0436
Practice Address - Street 1:1224 NORLEY AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-4074
Practice Address - Country:US
Practice Address - Phone:815-690-0213
Practice Address - Fax:815-846-0436
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14173101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)