Provider Demographics
NPI:1952547903
Name:DEATON, TRAVIS VAN
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:VAN
Last Name:DEATON
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 1:51960 GUMWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6207
Mailing Address - Country:US
Mailing Address - Phone:574-247-4665
Mailing Address - Fax:
Practice Address - Street 1:51960 GUMWOOD RD.
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7068
Practice Address - Country:US
Practice Address - Phone:574-247-4665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-22
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200429240Medicaid