Provider Demographics
NPI:1275186512
Name:KNOWLTON, TRAVIS EDWARD (LCSW)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:EDWARD
Last Name:KNOWLTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LA VERNIA
Mailing Address - State:TX
Mailing Address - Zip Code:78121-4756
Mailing Address - Country:US
Mailing Address - Phone:760-859-7699
Mailing Address - Fax:
Practice Address - Street 1:4849 RONSON CT STE 207
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1805
Practice Address - Country:US
Practice Address - Phone:844-737-3638
Practice Address - Fax:619-403-9496
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA844882599101YM0800X
CA879841041C0700X
CA1182691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health