Provider Demographics
NPI:1134610413
Name:BAILEY, TRAVIS (PSYD, EDS)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:BAILEY
Suffix:
Gender:M
Credentials:PSYD, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:VA
Mailing Address - Zip Code:22963-2407
Mailing Address - Country:US
Mailing Address - Phone:804-337-5647
Mailing Address - Fax:
Practice Address - Street 1:1918 THOMAS JEFFERSON PKWY
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:VA
Practice Address - Zip Code:22963-4836
Practice Address - Country:US
Practice Address - Phone:434-589-3666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005617103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical