Basic Information
| Provider Information | |||||||||
| NPI: | 1538599006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLBSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | TRAVIS | ||||||||
| OtherMiddleName: | MARK | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLBSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1800 W BIG BEAVER RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480843535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489185600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 W BIG BEAVER RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480843535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489185600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802087942 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 171M00000X | 05 | MI | MEDICAID |