Provider Demographics
NPI:1033937149
Name:TRAVERS, ELLIS (CCHW)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:TRAVERS
Suffix:
Gender:X
Credentials:CCHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 BAINBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1810
Mailing Address - Country:US
Mailing Address - Phone:215-563-0658
Mailing Address - Fax:877-316-4122
Practice Address - Street 1:1348 BAINBRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1810
Practice Address - Country:US
Practice Address - Phone:215-563-0658
Practice Address - Fax:877-316-4122
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA20215172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker