Provider Demographics
NPI:1295123222
Name:LENFEST, TRAVIS JEROME (LCSW, LADC, CCS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JEROME
Last Name:LENFEST
Suffix:
Gender:M
Credentials:LCSW, LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 STATE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5317
Mailing Address - Country:US
Mailing Address - Phone:207-631-8968
Mailing Address - Fax:
Practice Address - Street 1:139 STATE ST STE 2
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5317
Practice Address - Country:US
Practice Address - Phone:207-631-8968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECCS5117101YA0400X
MELC4633101YA0400X
MELC180741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)