Healthcare Provider Details

I. General information

NPI: 1124644596
Provider Name (Legal Business Name): TRAVIS JAMES ATKINSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 WAUSAUKEE DR NE
GRAND RAPIDS MI
49525-1916
US

IV. Provider business mailing address

3000 WAUSAUKEE DR NE
GRAND RAPIDS MI
49525-1916
US

V. Phone/Fax

Practice location:
  • Phone: 616-914-0985
  • Fax:
Mailing address:
  • Phone: 616-914-0985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012242
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: