Provider Demographics
NPI:1982130191
Name:TRAVENICK, GRAHAM (BCBA)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:
Last Name:TRAVENICK
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SIMPSON CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-6714
Mailing Address - Country:US
Mailing Address - Phone:925-323-0083
Mailing Address - Fax:
Practice Address - Street 1:400 29TH ST STE 204
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3547
Practice Address - Country:US
Practice Address - Phone:415-748-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-25775103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst