MEDICARE: TRAVIS CLARK HALL CADCII

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	540	GA

General Provider Information

NPI Number	:	1598269334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS CLARK HALL CADCII

Provider Business Mailing Address
First Line	:	2402 TIFT AVE N
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-1883
Country	:	US
Telephone Number	:	229-382-7898
Fax Number	:	229-386-5818

Provider Business Practice Location Address
First Line	:	2402 TIFT AVE N
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-1883
Country	:	US
Telephone Number	:	229-382-7898
Fax Number	:	229-386-5818

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2018
Last Update Date	:	03/19/2018

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