Healthcare Provider Details

I. General information

NPI: 1558798835
Provider Name (Legal Business Name): ROBERT CHRISTOPHER TRAVIS MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4703 MILNE DR
TORRANCE CA
90505-3337
US

IV. Provider business mailing address

921 S BEACON ST
SAN PEDRO CA
90731-3740
US

V. Phone/Fax

Practice location:
  • Phone: 424-903-9333
  • Fax:
Mailing address:
  • Phone: 424-903-9333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number114771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: