Provider Demographics
NPI:1346887247
Name:WHITE, TRAVAUGHN DOMINIC
Entity Type:Individual
Prefix:
First Name:TRAVAUGHN
Middle Name:DOMINIC
Last Name:WHITE
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 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:216-372-3523
Mailing Address - Fax:
Practice Address - Street 1:3500 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2641
Practice Address - Country:US
Practice Address - Phone:216-372-3523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251S00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHVB326494Medicaid