Provider Demographics
NPI:1619588142
Name:TRAVIS, AMY WRIGHT (LCSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:WRIGHT
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 EAST BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5156
Mailing Address - Country:US
Mailing Address - Phone:704-980-3082
Mailing Address - Fax:540-961-8465
Practice Address - Street 1:700 EAST BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5156
Practice Address - Country:US
Practice Address - Phone:704-980-3082
Practice Address - Fax:540-961-8465
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0138481041C0700X
VA09040115341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical