Provider Demographics
NPI:1609017615
Name:VICK, TRAVIS PHILIP (MA)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:PHILIP
Last Name:VICK
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-2250
Mailing Address - Country:US
Mailing Address - Phone:254-292-9949
Mailing Address - Fax:
Practice Address - Street 1:3417 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-2250
Practice Address - Country:US
Practice Address - Phone:254-292-9949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63056101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional