MEDICARE: TRAVIS SCOTT BLEVINS M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist
2	103TF0000X	Family Psychologist
3	103TM1800X	Intellectual & Developmental Disabilities Psychologist
4	103K00000X	Behavior Analyst	1-05-2144	CO

General Provider Information

NPI Number	:	1700068418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS SCOTT BLEVINS M.S.

Provider Business Mailing Address
First Line	:	PO BOX 271690
Second Line	:
City	:	LOUISVILLE
State	:	CO
Zip	:	80027-5035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 W SOUTH BOULDER RD
Second Line	:	STE. 204
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-3546
Country	:	US
Telephone Number	:	720-837-2348
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2007
Last Update Date	:	01/18/2017

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