Basic Information
Provider Information | |||||||||
NPI: | 1306419502 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUBER | ||||||||
FirstName: | TRAVIS | ||||||||
MiddleName: | BEAU | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6825 RUDDELL RD SE | ||||||||
Address2: |   | ||||||||
City: | LACEY | ||||||||
State: | WA | ||||||||
PostalCode: | 985135235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607906513 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3857 MARTIN WAY E | ||||||||
Address2: |   | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 985065268 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607047170 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2021 | ||||||||
LastUpdateDate: | 07/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.