Healthcare Provider Details

I. General information

NPI: 1497939862
Provider Name (Legal Business Name): TRAVIS LEE BAILEY CADC-II, ICADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

IV. Provider business mailing address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

V. Phone/Fax

Practice location:
  • Phone: 530-855-1917
  • Fax: 530-885-1169
Mailing address:
  • Phone: 530-855-1917
  • Fax: 530-885-1169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA01990315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: