Healthcare Provider Details

I. General information

NPI: 1790477503
Provider Name (Legal Business Name): TRAVIS DEWITT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 E 390TH RD
DUNNEGAN MO
65640-9634
US

IV. Provider business mailing address

749 E 390TH RD
DUNNEGAN MO
65640-9634
US

V. Phone/Fax

Practice location:
  • Phone: 253-278-1841
  • Fax:
Mailing address:
  • Phone: 253-278-1841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: