Healthcare Provider Details

I. General information

NPI: 1295196335
Provider Name (Legal Business Name): TRAVIS VANOOSTEN RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 LOGAN ST SE
GRAND RAPIDS MI
49503-5528
US

IV. Provider business mailing address

711 LOGAN ST SE
GRAND RAPIDS MI
49503-5528
US

V. Phone/Fax

Practice location:
  • Phone: 616-516-7152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-15-01121
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: