Provider Demographics
NPI:1366897787
Name:TERRELL, TRAVIS (LPCC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:TERRELL
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 R DUKE LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5754
Mailing Address - Country:US
Mailing Address - Phone:270-703-1332
Mailing Address - Fax:
Practice Address - Street 1:297 R DUKE LN
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5754
Practice Address - Country:US
Practice Address - Phone:270-703-1332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCPCC00223172101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional