Provider Demographics
NPI:1215417852
Name:BOGAN, TRAVIS CORROW (LPC-A, NCC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:CORROW
Last Name:BOGAN
Suffix:
Gender:M
Credentials:LPC-A, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 BATTLEGROUND AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2104
Mailing Address - Country:US
Mailing Address - Phone:336-543-0172
Mailing Address - Fax:844-642-5118
Practice Address - Street 1:430 BATTLEGROUND AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2104
Practice Address - Country:US
Practice Address - Phone:336-543-0172
Practice Address - Fax:844-642-5118
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA14098101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional