Basic Information
| Provider Information | |||||||||
| NPI: | 1811973506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRAVIS-WARD | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2336 GODDARD PKWY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218011126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103346961 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Practice Location | |||||||||
| Address1: | 11559 SOMERSET AVE | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218531022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106514200 | ||||||||
| FaxNumber: | 4106514290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | G11777 | MD | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 16822 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 522156095 | 01 | MD | APS HEALTHCARE | OTHER | 522156095 | 01 | MD | MHNET BEHAVIORAL HEALTH | OTHER | 609550002 | 05 | MD | MEDICAID | 609550001 | 05 | MD | MEDICAID | 522156095 | 01 | MD | COMMERCIAL | OTHER | 609550004 | 05 | MD | MEDICAID | LM49EA | 01 | MD | CAREFIRST BCBS - LOCAL | OTHER | R968 | 01 | MD | CAREFIRST BCBS - FEDERAL | OTHER |