Provider Demographics
NPI:1902249238
Name:TRAVIS, LARRY R (LCMHT/LSW/CCSS-II)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:LCMHT/LSW/CCSS-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1
Mailing Address - Street 2:3550 HIGHWAY, 468 WEST FISCAL SERVICES
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:
Practice Address - Street 1:3550 HIGHWAY, 468 WEST
Practice Address - Street 2:FISCAL SERVICES
Practice Address - City:WHITFIELD
Practice Address - State:MS
Practice Address - Zip Code:39193-0157
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0084101YM0800X
MSW0709104100000X
MS0367171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator