Provider Demographics
NPI:1770724155
Name:TRAVIS, AMANDA ROSE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ROSE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:TROUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:2163 BOWLES RNCH
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-5866
Mailing Address - Country:US
Mailing Address - Phone:575-635-8947
Mailing Address - Fax:254-519-3464
Practice Address - Street 1:2206 E CENTRAL TEXAS EXPY
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5315
Practice Address - Country:US
Practice Address - Phone:254-519-4162
Practice Address - Fax:254-519-3464
Is Sole Proprietor?:No
Enumeration Date:2009-03-16
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-062481041C0700X
TX676711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80137857Medicaid