MEDICARE: TRAVIS LOGAN JUSTICE BA, CADC

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		PA

General Provider Information

NPI Number	:	1700603099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS LOGAN JUSTICE BA, CADC

Provider Business Mailing Address
First Line	:	4040 MARKET ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3003
Country	:	US
Telephone Number	:	443-889-0292
Fax Number	:

Provider Business Practice Location Address
First Line	:	4040 MARKET ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3003
Country	:	US
Telephone Number	:	215-662-8747
Fax Number	:

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

Provider Enumeration Date	:	09/26/2024
Last Update Date	:	03/16/2026

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