Basic Information
| Provider Information | |||||||||
| NPI: | 1033252622 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3820 E 180 N | ||||||||
| Address2: | |||||||||
| City: | RIGBY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087450639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1337 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834046235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-27235 | ID | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.