Provider Demographics
NPI:1053843425
Name:TRAVIS, LISA JEAN
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JEAN
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SOUTH 168TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49524
Mailing Address - Country:US
Mailing Address - Phone:616-886-0649
Mailing Address - Fax:
Practice Address - Street 1:668 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8219
Practice Address - Country:US
Practice Address - Phone:616-649-3129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician