Provider Demographics
NPI:1598812844
Name:WIGGETT, TRAVIS (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WIGGETT
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAINE ST STE 216D
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2082
Mailing Address - Country:US
Mailing Address - Phone:207-406-2697
Mailing Address - Fax:
Practice Address - Street 1:14 MAINE ST STE 216D
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2082
Practice Address - Country:US
Practice Address - Phone:207-406-2697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC3364101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI413206OtherBLUE CHIP
RIFM49368Medicaid
RI31234-7OtherBLUE CROSS