Provider Demographics
NPI:1154189538
Name:ADAMS, TRAVIS BLAKE
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:BLAKE
Last Name:ADAMS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3257 YARMOUTH LN
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-7875
Mailing Address - Country:US
Mailing Address - Phone:704-813-3643
Mailing Address - Fax:
Practice Address - Street 1:407 MULBERRY ST SW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5722
Practice Address - Country:US
Practice Address - Phone:828-394-6722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC287014163WP0808X
NC5020249363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health