Healthcare Provider Details

I. General information

NPI: 1568488724
Provider Name (Legal Business Name): TRAVIS WAITS MA, LMFT, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18650 SW BOONES FERRY RD SUITE 3
TUALATIN OR
97062-8491
US

IV. Provider business mailing address

18650 SW BOONES FERRY RD SUITE 3
TUALATIN OR
97062-8491
US

V. Phone/Fax

Practice location:
  • Phone: 503-680-4734
  • Fax: 503-536-6839
Mailing address:
  • Phone: 503-680-4734
  • Fax: 503-536-6839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0623
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2157
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: