Provider Demographics
NPI:1194280297
Name:TRAVIS, PHILICIA
Entity type:Individual
Prefix:
First Name:PHILICIA
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21433 JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:70444-7365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1312 N. MORRISON BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401
Practice Address - Country:US
Practice Address - Phone:985-551-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator