Provider Demographics
NPI:1598269334
Name:HALL, TRAVIS CLARK (CADCII)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:CLARK
Last Name:HALL
Suffix:
Gender:M
Credentials:CADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 TIFT AVE N
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1883
Mailing Address - Country:US
Mailing Address - Phone:229-382-7898
Mailing Address - Fax:229-386-5818
Practice Address - Street 1:2402 TIFT AVE N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1883
Practice Address - Country:US
Practice Address - Phone:229-382-7898
Practice Address - Fax:229-386-5818
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA540101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)