Provider Demographics
NPI:1588282677
Name:TRAVIS, MELVA (MA)
Entity type:Individual
Prefix:
First Name:MELVA
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 PACIFIC COAST HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2227
Mailing Address - Country:US
Mailing Address - Phone:310-406-1500
Mailing Address - Fax:
Practice Address - Street 1:4688 ONTARIO MILLS PKWY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5104
Practice Address - Country:US
Practice Address - Phone:909-476-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-97259106S00000X
CA12147181103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician