Healthcare Provider Details

I. General information

NPI: 1194017269
Provider Name (Legal Business Name): KIMBERLY TRAVIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10208 S INDIANAPOLIS AVE STE 301
CHICAGO IL
60617-6033
US

IV. Provider business mailing address

1101 CUMBERLAND XING # 108
VALPARAISO IN
46383-2356
US

V. Phone/Fax

Practice location:
  • Phone: 866-413-1988
  • Fax: 866-628-8599
Mailing address:
  • Phone: 866-413-1988
  • Fax: 866-628-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149.014508
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006318A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: