Provider Demographics
NPI:1114644044
Name:MIKEL, TRAVIS DE'JOHN (MSW, ASW, PPSC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DE'JOHN
Last Name:MIKEL
Suffix:
Gender:M
Credentials:MSW, ASW, PPSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4051 S CENTRAL AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-2779
Mailing Address - Country:US
Mailing Address - Phone:323-317-5268
Mailing Address - Fax:
Practice Address - Street 1:710 E 111TH PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-1518
Practice Address - Country:US
Practice Address - Phone:323-233-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111220104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker