Healthcare Provider Details

I. General information

NPI: 1063330603
Provider Name (Legal Business Name): TRAVIS WELTON WASHINGTON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BRUSH ST
UKIAH CA
95482-3424
US

IV. Provider business mailing address

214 NORTON ST APT 5B
UKIAH CA
95482-4434
US

V. Phone/Fax

Practice location:
  • Phone: 707-462-6290
  • Fax:
Mailing address:
  • Phone: 707-462-1934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1441900526
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: