Provider Demographics
NPI:1568688711
Name:WILSON, TRAVIS DEAN (LCPC, ACADC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:DEAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:LCPC, ACADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8258 W ORBIT DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-7876
Mailing Address - Country:US
Mailing Address - Phone:208-850-2798
Mailing Address - Fax:
Practice Address - Street 1:8258 W ORBIT DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-7876
Practice Address - Country:US
Practice Address - Phone:208-850-2798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health