Healthcare Provider Details

I. General information

NPI: 1952022063
Provider Name (Legal Business Name): TRAVIS EDWARD HENDERSON DNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3655 E GRANT RD
TUCSON AZ
85716-2933
US

IV. Provider business mailing address

839 W CONGRESS ST
TUCSON AZ
85745-2819
US

V. Phone/Fax

Practice location:
  • Phone: 520-670-3909
  • Fax: 520-309-2560
Mailing address:
  • Phone: 520-670-3909
  • Fax: 520-309-2560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number266188
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number266188
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: