Provider Demographics
NPI:1104239680
Name:CONSTANCE, TRAVIS (LCDC,LPC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:CONSTANCE
Suffix:
Gender:M
Credentials:LCDC,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2374
Mailing Address - Country:US
Mailing Address - Phone:614-231-1890
Mailing Address - Fax:614-231-4978
Practice Address - Street 1:1070 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-2374
Practice Address - Country:US
Practice Address - Phone:614-231-1890
Practice Address - Fax:614-231-4978
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC141119-3101YA0400X
OHC1300200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional