Healthcare Provider Details

I. General information

NPI: 1639365174
Provider Name (Legal Business Name): TRAVIS A COS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CALLOWHILL ST PHMC CARE CLINIC, SUITE 101
PHILADELPHIA PA
19123-3658
US

IV. Provider business mailing address

1500 MARKET STREET LM 500 WEST TOWER
PHILADELPHIA PA
19120-2100
US

V. Phone/Fax

Practice location:
  • Phone: 215-825-8220
  • Fax: 215-825-8254
Mailing address:
  • Phone: 215-985-2595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016774
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number018246-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: