Provider Demographics
NPI:1568647915
Name:BERRY-TRAVIS, RENEE A
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:BERRY-TRAVIS
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 1:1410 GUERNEVILLE RD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7231
Mailing Address - Country:US
Mailing Address - Phone:707-575-0979
Mailing Address - Fax:
Practice Address - Street 1:1410 GUERNEVILLE RD
Practice Address - Street 2:SUITE 14
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7231
Practice Address - Country:US
Practice Address - Phone:707-575-0979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-04
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor