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General NPI Number Information
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NPI Number | 1205448560
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Entity Type | Individual
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Provider Name | TRAVIS NOLAN LCSW
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Gender | Male
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Dates
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Enumeration Date | 08/18/2020
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Last Update Date | 02/03/2022
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Provider Practice Location Address
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Address Line | 2200 MARSH HAWK LN UNIT 615
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-4315
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Country | US
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Telephone | 904-294-7247
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Fax |
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Provider Business Mailing Address
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Address Line | 2200 MARSH HAWK LN UNIT 615
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City | FLEMING ISLAND
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State | FL
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Zip | 32003-4315
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Country | US
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Telephone | 904-294-7247
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | SW17486
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW17486
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License Number State | FL
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