Provider Demographics
NPI:1366823395
Name:WASHINGTON, TRAVIA LINETTE
Entity Type:Individual
Prefix:
First Name:TRAVIA
Middle Name:LINETTE
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2959 SHERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805-4058
Mailing Address - Country:US
Mailing Address - Phone:225-726-6252
Mailing Address - Fax:
Practice Address - Street 1:2959 SHERWOOD ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805
Practice Address - Country:US
Practice Address - Phone:225-726-6252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA47-3957036172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366823395Medicaid