Provider Demographics
NPI:1881101020
Name:TRAVIS, KENYETTA ROSE
Entity type:Individual
Prefix:
First Name:KENYETTA
Middle Name:ROSE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4177 WESTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-1867
Mailing Address - Country:US
Mailing Address - Phone:614-330-0647
Mailing Address - Fax:
Practice Address - Street 1:4200 REGENT ST STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6229
Practice Address - Country:US
Practice Address - Phone:614-420-2268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS00305781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical