Healthcare Provider Details

I. General information

NPI: 1376162214
Provider Name (Legal Business Name): ANTONIA TRAVISANO PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COMMERCE DR BUILDING 100, STE 300
NEWARK DE
19713-2878
US

IV. Provider business mailing address

100 COMMERCE DR BUILDING 100, STE 300
NEWARK DE
19713-2878
US

V. Phone/Fax

Practice location:
  • Phone: 302-224-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007634
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberB1-0011441
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: