Provider Demographics
NPI:1134574650
Name:ANDERSON, TRAVIS (MSW)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0249
Mailing Address - Country:US
Mailing Address - Phone:269-655-3334
Mailing Address - Fax:269-381-3810
Practice Address - Street 1:801 HAZEN ST STE C
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-2008
Practice Address - Country:US
Practice Address - Phone:269-655-3334
Practice Address - Fax:269-381-3810
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI60811053401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical