1427234285 NPI number — MR. TRAVIS MICHAEL WHITE MA, LPC-S

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427234285 NPI number — MR. TRAVIS MICHAEL WHITE MA, LPC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
TRAVIS
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC-S
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427234285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 43
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BULLARD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75757-0043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-780-3477
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-4054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-780-3477
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  63524 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)