Provider Demographics
NPI:1679941595
Name:CAVAZOS, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:CAVAZOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1177
Mailing Address - Country:US
Mailing Address - Phone:270-678-4801
Mailing Address - Fax:270-678-3866
Practice Address - Street 1:1048 ASHLEY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-2449
Practice Address - Country:US
Practice Address - Phone:270-904-6567
Practice Address - Fax:270-904-6570
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCCA00218829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health