Provider Demographics
NPI:1306405121
Name:FRAGALE, TRAVIS (LPC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:FRAGALE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 AVENUE C
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07716-1134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 AVENUE C
Practice Address - Street 2:
Practice Address - City:ATLANTIC HIGHLANDS
Practice Address - State:NJ
Practice Address - Zip Code:07716-1134
Practice Address - Country:US
Practice Address - Phone:732-337-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00946500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional