Provider Demographics
NPI:1245864958
Name:SMITH, TRAVIS DALE (LPC)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 W NORTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4936
Mailing Address - Country:US
Mailing Address - Phone:602-995-1767
Mailing Address - Fax:602-995-1863
Practice Address - Street 1:2255 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4936
Practice Address - Country:US
Practice Address - Phone:602-995-1767
Practice Address - Fax:602-995-1863
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-18444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty