Provider Demographics
NPI:1043774565
Name:TRAVIS, ALICIA JEORGE (LMSW)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:JEORGE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8122 JACK PINE DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7530
Mailing Address - Country:US
Mailing Address - Phone:734-474-3743
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE 4001
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197
Practice Address - Country:US
Practice Address - Phone:734-712-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010965431041C0700X
MI68011093101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical