Provider Demographics
NPI:1275670390
Name:TRAVIS, MARY ANN (BS,MA,EDS,PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:BS,MA,EDS,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2310
Mailing Address - Country:US
Mailing Address - Phone:407-644-1522
Mailing Address - Fax:
Practice Address - Street 1:2150 N PARK AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2310
Practice Address - Country:US
Practice Address - Phone:407-644-1522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS 672103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool