Provider Demographics
NPI:1053583179
Name:TRAVIS, RICHARD BRODE (PHD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRODE
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 1:11712 MOORPARK ST
Mailing Address - Street 2:205B
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2154
Mailing Address - Country:US
Mailing Address - Phone:818-766-5988
Mailing Address - Fax:818-766-1104
Practice Address - Street 1:11712 MOORPARK ST
Practice Address - Street 2:205B
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2154
Practice Address - Country:US
Practice Address - Phone:818-766-5988
Practice Address - Fax:818-766-1104
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT14361106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist