Provider Demographics
NPI:1790477503
Name:DEWITT, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:DEWITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 E 390TH RD
Mailing Address - Street 2:
Mailing Address - City:DUNNEGAN
Mailing Address - State:MO
Mailing Address - Zip Code:65640-9634
Mailing Address - Country:US
Mailing Address - Phone:253-278-1841
Mailing Address - Fax:
Practice Address - Street 1:749 E 390TH RD
Practice Address - Street 2:
Practice Address - City:DUNNEGAN
Practice Address - State:MO
Practice Address - Zip Code:65640-9634
Practice Address - Country:US
Practice Address - Phone:253-278-1841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral