Provider Demographics
NPI:1467969360
Name:BURNARD-TRAVIS, TABITHA ANN
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:ANN
Last Name:BURNARD-TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:ANN
Other - Last Name:BURNARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:1823 BUSINESS PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1230
Mailing Address - Country:US
Mailing Address - Phone:386-254-1931
Mailing Address - Fax:
Practice Address - Street 1:1823 BUSINESS PARK BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1230
Practice Address - Country:US
Practice Address - Phone:386-254-1931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)