Provider Demographics
NPI:1407615420
Name:TRAVICK, DARESA
Entity Type:Individual
Prefix:
First Name:DARESA
Middle Name:
Last Name:TRAVICK
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 1:19913 KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-2243
Mailing Address - Country:US
Mailing Address - Phone:313-900-6224
Mailing Address - Fax:
Practice Address - Street 1:19750 BURT RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-2078
Practice Address - Country:US
Practice Address - Phone:313-255-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator