Provider Demographics
NPI:1982102893
Name:WORRELL, TRAVIS G (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:G
Last Name:WORRELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 COMMONWEALTH BLVD E
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1917
Mailing Address - Country:US
Mailing Address - Phone:276-403-5779
Mailing Address - Fax:276-403-5178
Practice Address - Street 1:351 COMMONWEALTH BLVD E
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1917
Practice Address - Country:US
Practice Address - Phone:276-403-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
VA0183000199103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool