Basic Information
| Provider Information | |||||||||
| NPI: | 1497939862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | CADC-II, ICADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12125 SHALE RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956028880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308551917 | ||||||||
| FaxNumber: | 5308851169 | ||||||||
| Practice Location | |||||||||
| Address1: | 12125 SHALE RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956028880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308551917 | ||||||||
| FaxNumber: | 5308851169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | A01990315 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.