Healthcare Provider Details

I. General information

NPI: 1487323820
Provider Name (Legal Business Name): TRAVIS W. JOHNSON SR. M.A., LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4318 WOODCOCK DR STE 120
SAN ANTONIO TX
78228-1315
US

IV. Provider business mailing address

5118 GREEN CORAL
SAN ANTONIO TX
78223-4543
US

V. Phone/Fax

Practice location:
  • Phone: 210-719-0237
  • Fax: 210-547-0256
Mailing address:
  • Phone: 210-719-0237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number78681
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number78681
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number78681
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number78681
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number78681
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: