Provider Demographics
NPI:1962453159
Name:STRATFORD, TRAVIS W (MD, LCPC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:W
Last Name:STRATFORD
Suffix:
Gender:M
Credentials:MD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 RIVER RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-8503
Mailing Address - Country:US
Mailing Address - Phone:406-317-3115
Mailing Address - Fax:
Practice Address - Street 1:1703 RIVER RANCH RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-8503
Practice Address - Country:US
Practice Address - Phone:406-317-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT47167101YP2500X, 101YM0800X
OR269782085R0202X
WAMD460392085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR271184Medicaid
ORI66211Medicare UPIN