Provider Demographics
NPI:1679162887
Name:AUDIA, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:AUDIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 NW HARMON BLVD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-3060
Mailing Address - Country:US
Mailing Address - Phone:541-591-4275
Mailing Address - Fax:
Practice Address - Street 1:1 SERENITY LN
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9350
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-20-490101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)