Provider Demographics
NPI:1780194282
Name:CARDWELL, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:CARDWELL
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 1:940 AVENUE 64
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2711
Mailing Address - Country:US
Mailing Address - Phone:323-543-2800
Mailing Address - Fax:
Practice Address - Street 1:3636 N 1ST ST STE 124112
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6800
Practice Address - Country:US
Practice Address - Phone:559-476-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner