Provider Demographics
NPI:1003155219
Name:VANDERLIST, TRAVIS JOHN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:JOHN
Last Name:VANDERLIST
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2628
Mailing Address - Country:US
Mailing Address - Phone:517-303-3969
Mailing Address - Fax:
Practice Address - Street 1:1500 WEISS ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5251
Practice Address - Country:US
Practice Address - Phone:989-497-2500
Practice Address - Fax:989-321-4922
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010904231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical