Provider Demographics
NPI:1689470668
Name:DEBERRY, TRAVIS (LGPC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:DEBERRY
Suffix:
Gender:
Credentials:LGPC
Other - Prefix:
Other - First Name:AMENZA
Other - Middle Name:
Other - Last Name:DEBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LGPC
Mailing Address - Street 1:8400 BALTIMORE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2496
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8400 BALTIMORE AVE STE 300
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2496
Practice Address - Country:US
Practice Address - Phone:240-630-4137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15871101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor