Healthcare Provider Details

I. General information

NPI: 1295327146
Provider Name (Legal Business Name): MR. TRAVIS KINCAID
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 SANTA FE SPRINGS RD
SANTA FE SPRINGS CA
90670-2621
US

IV. Provider business mailing address

9300 SANTA FE SPRINGS RD
SANTA FE SPRINGS CA
90670-2621
US

V. Phone/Fax

Practice location:
  • Phone: 562-243-0462
  • Fax:
Mailing address:
  • Phone: 562-273-0462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-JKYHQE
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1423090321
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: