MEDICARE: TRAVIS A GATERS III

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1962050641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS A GATERS III

Provider Business Mailing Address
First Line	:	7624 N PORTSMOUTH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-5954
Country	:	US
Telephone Number	:	503-317-6762
Fax Number	:

Provider Business Practice Location Address
First Line	:	7624 N PORTSMOUTH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-5954
Country	:	US
Telephone Number	:	503-317-6762
Fax Number	:

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

Provider Enumeration Date	:	08/27/2019
Last Update Date	:	08/27/2019

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Directions to “ TRAVIS A GATERS III ” Practice Location

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