Provider Demographics
NPI:1376300350
Name:TRAVIS, LAKENYA (PCMHT)
Entity Type:Individual
Prefix:
First Name:LAKENYA
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:PCMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:601-705-1952
Practice Address - Street 1:116 JE JOHNSON RD
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-3104
Practice Address - Country:US
Practice Address - Phone:601-792-4872
Practice Address - Fax:601-792-2643
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6380101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health