Provider Demographics
NPI:1902989122
Name:TRAVIS, RICHARD D JR (PSYD, LCP)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:TRAVIS
Suffix:JR
Gender:M
Credentials:PSYD, LCP
Other - Prefix:DR
Other - First Name:BO
Other - Middle Name:
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD, LCP
Mailing Address - Street 1:24123 W LOCKPORT ST
Mailing Address - Street 2:UNIT 101
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2863
Mailing Address - Country:US
Mailing Address - Phone:815-436-1101
Mailing Address - Fax:815-436-1121
Practice Address - Street 1:24123 W LOCKPORT ST
Practice Address - Street 2:UNIT 101
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-2863
Practice Address - Country:US
Practice Address - Phone:815-436-1101
Practice Address - Fax:815-436-1121
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003461101YP2500X
IL071.008003103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11723317OtherAETNA
IL0009932335OtherBCBS IL
IL581473OtherVALUE OPTIONS
IL802121000OtherMAGELLAN