Provider Demographics
NPI:1033910203
Name:TRAVIS, GREGORY KNIGHT (PHD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:KNIGHT
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2036 W 28TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-3049
Mailing Address - Country:US
Mailing Address - Phone:323-935-3885
Mailing Address - Fax:
Practice Address - Street 1:6310 SAN VICENTE BLVD STE 410
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5457
Practice Address - Country:US
Practice Address - Phone:323-935-3885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-22
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12181103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral