Provider Demographics
NPI:1154076370
Name:FISCHER, TRAVIS RANDALL
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:RANDALL
Last Name:FISCHER
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 1:46900 MONROE ST STE A101
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-4828
Mailing Address - Country:US
Mailing Address - Phone:760-863-7219
Mailing Address - Fax:
Practice Address - Street 1:46900 MONROE ST STE A101
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-4828
Practice Address - Country:US
Practice Address - Phone:760-863-7219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1458280222101YA0400X
172V00000X, 175T00000X
CAMPSS-TBYHIP175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker