Healthcare Provider Details

I. General information

NPI: 1821926379
Provider Name (Legal Business Name): TRAVIS S BOULDIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 W CROSS ST
BALTIMORE MD
21230-2534
US

IV. Provider business mailing address

1022 W CROSS ST
BALTIMORE MD
21230-2534
US

V. Phone/Fax

Practice location:
  • Phone: 301-741-1429
  • Fax:
Mailing address:
  • Phone: 301-741-1429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: