Provider Demographics
NPI:1811307903
Name:UNDERWOOD, TRAVIS (LISW)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BURLINGTON
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3242
Mailing Address - Country:US
Mailing Address - Phone:641-682-8772
Mailing Address - Fax:641-682-1924
Practice Address - Street 1:226 WEST MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2520
Practice Address - Country:US
Practice Address - Phone:641-682-4804
Practice Address - Fax:641-814-5684
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007987104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1659353670OtherBCBS
IA1659353670Medicaid