Provider Demographics
NPI:1013793165
Name:TRAVIS, VELLA MAE (CSW)
Entity Type:Individual
Prefix:
First Name:VELLA
Middle Name:MAE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112B ENSMINGER DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1157
Mailing Address - Country:US
Mailing Address - Phone:270-629-6138
Mailing Address - Fax:270-629-3076
Practice Address - Street 1:112B ENSMINGER DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1157
Practice Address - Country:US
Practice Address - Phone:270-629-6138
Practice Address - Fax:270-629-3076
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY55091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical