Basic Information
| Provider Information | |||||||||
| NPI: | 1487391017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22415 SE 231ST ST STE B-10 | ||||||||
| Address2: | |||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980385000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 22415 SE 231ST ST STE B-10 | ||||||||
| Address2: | |||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980385000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259064300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2022 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-22-13613 | N | 106E00000X | LABA.AB.61297640 | WA | Y |
ID Information
| ID | Type | State | Issuer | Description | 0-22-13613 | 01 | BOARD CERTIFIED ASSISTANT BEHAVIOR ANALYST | OTHER | BACB491785 | 01 | BOARD ANALYST CERTIFICATION BOARD | OTHER |