Provider Demographics
NPI:1649536418
Name:HAASE, TRAVIS PAUL (LCPC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:PAUL
Last Name:HAASE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 SUNFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-7118
Mailing Address - Country:US
Mailing Address - Phone:208-340-6996
Mailing Address - Fax:
Practice Address - Street 1:413 N ALLUMBAUGH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9212
Practice Address - Country:US
Practice Address - Phone:208-323-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4901101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health