Healthcare Provider Details

I. General information

NPI: 1902989122
Provider Name (Legal Business Name): RICHARD D TRAVIS JR. PSY.D, LCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BO TRAVIS PSY.D, LCP

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24123 W LOCKPORT ST UNIT 101
PLAINFIELD IL
60544-2863
US

IV. Provider business mailing address

24123 W LOCKPORT ST UNIT 101
PLAINFIELD IL
60544-2863
US

V. Phone/Fax

Practice location:
  • Phone: 815-436-1101
  • Fax: 815-436-1121
Mailing address:
  • Phone: 815-436-1101
  • Fax: 815-436-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003461
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008003
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11723317
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerAETNA
# 2
Identifier0009932335
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS IL
# 3
Identifier581473
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerVALUE OPTIONS
# 4
Identifier802121000
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerMAGELLAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: