Provider Demographics
NPI:1992554919
Name:TRAVIS, KATIE ANN
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 S WELLS ST APT 8
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2494
Mailing Address - Country:US
Mailing Address - Phone:262-960-4115
Mailing Address - Fax:
Practice Address - Street 1:1165 S WELLS ST APT 8
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-2494
Practice Address - Country:US
Practice Address - Phone:262-960-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health