Healthcare Provider Details

I. General information

NPI: 1396887451
Provider Name (Legal Business Name): TRAVIS PORTER PSY, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 JET WING DR
COLORADO SPRINGS CO
80916
US

IV. Provider business mailing address

220 RUSKIN DR
COLORADO SPRINGS CO
80910
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6100
  • Fax: 719-572-6089
Mailing address:
  • Phone: 719-572-6100
  • Fax: 719-572-6080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0003920
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number203
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: