Provider Demographics
NPI:1477245678
Name:WASSERMAN, TRAVIS PAUL
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:PAUL
Last Name:WASSERMAN
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 1:3570 1ST AVE UNIT 19
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4897
Mailing Address - Country:US
Mailing Address - Phone:175-771-7410
Mailing Address - Fax:
Practice Address - Street 1:10065 OLD GROVE RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1664
Practice Address - Country:US
Practice Address - Phone:858-547-9803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist