Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 E CLARK ST
KENT CITY MI
49330-9747
US

IV. Provider business mailing address

61 E CLARK ST
KENT CITY MI
49330-9747
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 Number0-16-7134
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: