Healthcare Provider Details

I. General information

NPI: 1982130191
Provider Name (Legal Business Name): GRAHAM TRAVENICK BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 29TH ST STE 204
OAKLAND CA
94609-3547
US

IV. Provider business mailing address

5 SIMPSON CT
WALNUT CREEK CA
94596-6714
US

V. Phone/Fax

Practice location:
  • Phone: 415-748-8052
  • Fax:
Mailing address:
  • Phone: 925-323-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-25775
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: