Provider Demographics
NPI:1700996907
Name:TRAVIS, RICHARD L (EDD LMHC CAPP)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:EDD LMHC CAPP
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:L
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDD LMHC CAPP
Mailing Address - Street 1:1919 NE 45TH STREET
Mailing Address - Street 2:#122
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308
Mailing Address - Country:US
Mailing Address - Phone:954-776-7176
Mailing Address - Fax:954-776-7160
Practice Address - Street 1:1919 NE 45TH STREET
Practice Address - Street 2:#122
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-776-7176
Practice Address - Fax:954-776-7160
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL042101YA0400X
FLMH2294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z4960OtherBCBS