Healthcare Provider Details

I. General information

NPI: 1699862540
Provider Name (Legal Business Name): MARK CLARENCE TRAVIS LPCC, LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S HENRY ST
DELAWARE OH
43015-2978
US

IV. Provider business mailing address

437 N WASHINGTON ST
DELAWARE OH
43015-1241
US

V. Phone/Fax

Practice location:
  • Phone: 740-369-4482
  • Fax: 740-369-4908
Mailing address:
  • Phone: 740-363-6410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number902899
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE-0003460
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: