Provider Demographics
NPI:1700485430
Name:RICHARDSON, TRAVIS WILLIAM
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WILLIAM
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DOCTORS PARK STE 3G
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4531
Mailing Address - Country:US
Mailing Address - Phone:828-251-1478
Mailing Address - Fax:
Practice Address - Street 1:3 DOCTORS PARK STE 3G
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4531
Practice Address - Country:US
Practice Address - Phone:828-251-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-26709101YA0400X
NCP0146741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)