Provider Demographics
NPI:1750655890
Name:MITCHELL, TRAVIS A SR (PHYSICOLOGIST)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:A
Last Name:MITCHELL
Suffix:SR
Gender:M
Credentials:PHYSICOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8759 ANNETTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63147-1602
Mailing Address - Country:US
Mailing Address - Phone:314-381-4225
Mailing Address - Fax:314-381-4225
Practice Address - Street 1:8759 ANNETTA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63147-1602
Practice Address - Country:US
Practice Address - Phone:314-381-4225
Practice Address - Fax:314-381-4225
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4718101YA0400X
MO103101YA0400X
MO5653103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)