Provider Demographics
NPI:1588285159
Name:TRAVISANO, MICHAEL (PSYD, PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TRAVISANO
Suffix:
Gender:M
Credentials:PSYD, PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 COMMERCE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2878
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 COMMERCE DR STE 300
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2878
Practice Address - Country:US
Practice Address - Phone:302-224-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1780103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEB1-0011432OtherSTATE OF DELAWARE DIVISION OF PROFESSIONAL REGULATION