Provider Demographics
NPI:1659302396
Name:TRAVIS CORPORATION
Entity type:Organization
Organization Name:TRAVIS CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:617-441-1770
Mailing Address - Street 1:1705 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:617-516-5150
Mailing Address - Fax:617-442-6915
Practice Address - Street 1:1705 COLUMBUS AVE.
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119
Practice Address - Country:US
Practice Address - Phone:617-516-5150
Practice Address - Fax:617-442-6915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4211101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty