Provider Demographics
NPI:1134386758
Name:FORST, TRAVIS JON (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:JON
Last Name:FORST
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-4705
Mailing Address - Country:US
Mailing Address - Phone:715-842-3346
Mailing Address - Fax:715-842-3344
Practice Address - Street 1:903 2ND ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4705
Practice Address - Country:US
Practice Address - Phone:715-842-3346
Practice Address - Fax:715-842-3344
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6815-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39795200Medicaid