Provider Demographics
NPI:1922713585
Name:FORTENBERRY, TRAVIS R (LMFT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:R
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1159
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CA
Mailing Address - Zip Code:95570-1159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4470 W SUNSET BLVD STE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6309
Practice Address - Country:US
Practice Address - Phone:707-786-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132511106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist