Provider Demographics
NPI:1851015077
Name:BROADDUS, TRAVIS DEONTA
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:DEONTA
Last Name:BROADDUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7135 MINSTREL WAY STE 204-M2
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5255
Mailing Address - Country:US
Mailing Address - Phone:301-357-0038
Mailing Address - Fax:
Practice Address - Street 1:7135 MINSTREL WAY STE 204-M2
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5255
Practice Address - Country:US
Practice Address - Phone:301-357-0038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician