Provider Demographics
NPI:1538501390
Name:ANDERSON, TRAVIS STEVEN
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:STEVEN
Last Name:ANDERSON
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 1:569 BECKTON PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-2402
Mailing Address - Country:US
Mailing Address - Phone:763-222-8004
Mailing Address - Fax:
Practice Address - Street 1:569 BECKTON PARK AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-2402
Practice Address - Country:US
Practice Address - Phone:763-222-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst