Provider Demographics
NPI:1558470559
Name:GEISTERT, TRAVIS (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:GEISTERT
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 AUBURN ST
Mailing Address - Street 2:STE. 1G
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6004
Mailing Address - Country:US
Mailing Address - Phone:207-797-8255
Mailing Address - Fax:207-797-5560
Practice Address - Street 1:222 AUBURN ST
Practice Address - Street 2:STE. 1G
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6004
Practice Address - Country:US
Practice Address - Phone:207-797-8255
Practice Address - Fax:207-797-5560
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1255235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME060947OtherANTHEM BLUE CROSS AND BLU
ME254520099Medicaid