Provider Demographics
NPI:1699862540
Name:TRAVIS, MARK CLARENCE (LPCC, LICDC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:CLARENCE
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:LPCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1241
Mailing Address - Country:US
Mailing Address - Phone:740-363-6410
Mailing Address - Fax:
Practice Address - Street 1:250 S HENRY ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2978
Practice Address - Country:US
Practice Address - Phone:740-369-4482
Practice Address - Fax:740-369-4908
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH902899101YA0400X
OHE-0003460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health