Provider Demographics
NPI:1932527504
Name:HENDERSON, TRAVIS (RAS111101051535)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:RAS111101051535
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 N BEALE RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-6205
Mailing Address - Country:US
Mailing Address - Phone:530-749-8640
Mailing Address - Fax:530-749-8646
Practice Address - Street 1:1496 N BEALE RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-6205
Practice Address - Country:US
Practice Address - Phone:530-749-8640
Practice Address - Fax:530-749-8646
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111101051535101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)