Provider Demographics
NPI:1114015039
Name:SMITH, TRAVIS (LPC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 BROADWAY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-7321
Mailing Address - Country:US
Mailing Address - Phone:573-271-2008
Mailing Address - Fax:573-271-2008
Practice Address - Street 1:339 BROADWAY ST STE 102
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-7321
Practice Address - Country:US
Practice Address - Phone:573-271-2008
Practice Address - Fax:573-271-2008
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009023490101YM0800X
IDLPC3685101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807107600Medicaid