Healthcare Provider Details

I. General information

NPI: 1609445444
Provider Name (Legal Business Name): TRAVIS MARTIN SHIVLEY-SCOTT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 10/13/2026
Certification Date: 10/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

V. Phone/Fax

Practice location:
  • Phone: 916-843-7515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32064
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number32064
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number32064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: