Healthcare Provider Details

I. General information

NPI: 1164278198
Provider Name (Legal Business Name): MR. TRAVIS LEE DEYOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 CAPITOLA RD
SANTA CRUZ CA
95062-2912
US

IV. Provider business mailing address

4580 PAUL SWEET RD
SANTA CRUZ CA
95065-1016
US

V. Phone/Fax

Practice location:
  • Phone: 831-427-3500
  • Fax:
Mailing address:
  • Phone: 831-588-0589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: