Provider Demographics
NPI:1386116952
Name:PSOTA, TRAVIS ROBERT (BS, QMHA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ROBERT
Last Name:PSOTA
Suffix:
Gender:M
Credentials:BS, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 EXCEL DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8067
Mailing Address - Country:US
Mailing Address - Phone:541-630-3125
Mailing Address - Fax:
Practice Address - Street 1:3501 EXCEL DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8067
Practice Address - Country:US
Practice Address - Phone:541-630-3125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health