Provider Demographics
NPI:1952077604
Name:FARRAR, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:FARRAR
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 1:79 MECHANICS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1318
Mailing Address - Country:US
Mailing Address - Phone:774-230-1082
Mailing Address - Fax:
Practice Address - Street 1:79 MECHANICS ST APT 2
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1318
Practice Address - Country:US
Practice Address - Phone:774-601-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTHYP.0000531174400000X
106S00000X, 175L00000X
VT097.0135198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175L00000XOther Service ProvidersHomeopath