Provider Demographics
NPI:1629694567
Name:TRAVIS, ERIN RENEE (MA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:RENEE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7481 LEE HWY APT 605
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1719
Mailing Address - Country:US
Mailing Address - Phone:240-577-9302
Mailing Address - Fax:
Practice Address - Street 1:3915 OLD LEE HWY STE 23A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2432
Practice Address - Country:US
Practice Address - Phone:703-259-5617
Practice Address - Fax:703-552-2037
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704013239101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0704013239OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONS