Provider Demographics
NPI:1902980428
Name:TRAVIS, CHARITA J
Entity Type:Individual
Prefix:MISS
First Name:CHARITA
Middle Name:J
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 1:3944 BLACKWING CT APT 210R
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-1364
Mailing Address - Country:US
Mailing Address - Phone:901-634-6397
Mailing Address - Fax:
Practice Address - Street 1:1087 ALICE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38106-6543
Practice Address - Country:US
Practice Address - Phone:901-259-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health