Healthcare Provider Details

I. General information

NPI: 1386147114
Provider Name (Legal Business Name): TRAVIS VALDEZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 UNION AVE SE SUITE 200 (PRIVATE OFFICE 223)
OLYMPIA WA
98501-2059
US

IV. Provider business mailing address

109 W 27TH ST RM 5S
NEW YORK NY
10001-6208
US

V. Phone/Fax

Practice location:
  • Phone: 332-264-9443
  • Fax:
Mailing address:
  • Phone: 332-264-9443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0102205812
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number345940
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO.OP.70139265
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A25986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: