Provider Demographics
NPI:1851801831
Name:NUGENT, TRAVIS STEVEN JOHNSON (MFT-IT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:STEVEN JOHNSON
Last Name:NUGENT
Suffix:
Gender:M
Credentials:MFT-IT
Other - Prefix:
Other - First Name:TRAVIS
Other - Middle Name:STEVEN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3362
Mailing Address - Country:US
Mailing Address - Phone:920-226-9599
Mailing Address - Fax:
Practice Address - Street 1:1020 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3362
Practice Address - Country:US
Practice Address - Phone:920-226-9599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI604-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist