Healthcare Provider Details

I. General information

NPI: 1104488105
Provider Name (Legal Business Name): TRAVIS GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 12/22/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 E BELTLINE AVE NE BUILDING #1, SUITE 4
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

1001 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-5803
US

V. Phone/Fax

Practice location:
  • Phone: 616-232-6050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451017462
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: