Provider Demographics
NPI:1255453981
Name:TRAVIS, MARY (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 OLD MAMARONECK RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-2060
Mailing Address - Country:US
Mailing Address - Phone:914-693-0961
Mailing Address - Fax:
Practice Address - Street 1:20 OLD MAMARONECK RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-2060
Practice Address - Country:US
Practice Address - Phone:914-328-6022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0067861103T00000X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral