Provider Demographics
NPI:1871970335
Name:RIOS, TRAVIS LEE (MA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LEE
Last Name:RIOS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2111 SAN PABLO AVE UNIT 2105
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-5007
Mailing Address - Country:US
Mailing Address - Phone:510-854-0922
Mailing Address - Fax:510-990-9847
Practice Address - Street 1:1918 BONITA AVE STE 200
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1014
Practice Address - Country:US
Practice Address - Phone:510-854-0922
Practice Address - Fax:510-990-9847
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127349106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XMedicaid