Provider Demographics
NPI:1639365174
Name:COS, TRAVIS A (PHD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:A
Last Name:COS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 MARKET STREET
Mailing Address - Street 2:LM 500 WEST TOWER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2100
Mailing Address - Country:US
Mailing Address - Phone:215-985-2595
Mailing Address - Fax:
Practice Address - Street 1:1200 CALLOWHILL ST
Practice Address - Street 2:PHMC CARE CLINIC, SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-3658
Practice Address - Country:US
Practice Address - Phone:215-825-8220
Practice Address - Fax:215-825-8254
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
PAPS016774103TC0700X
NY018246-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA685661OtherTUFTS
MAM18708OtherBLUE CROSS
MA1312677Medicaid
MA1312677Medicaid