Provider Demographics
NPI:1396887451
Name:PORTER, TRAVIS (PSY, LAC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:PSY, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 RUSKIN DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910
Mailing Address - Country:US
Mailing Address - Phone:719-572-6100
Mailing Address - Fax:719-572-6080
Practice Address - Street 1:1795 JET WING DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:719-572-6089
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0003920103TC0700X
CO203101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)