Healthcare Provider Details

I. General information

NPI: 1962453159
Provider Name (Legal Business Name): TRAVIS W STRATFORD M.D., L.C.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 RIVER RANCH RD
MISSOULA MT
59804-8503
US

IV. Provider business mailing address

1703 RIVER RANCH RD
MISSOULA MT
59804-8503
US

V. Phone/Fax

Practice location:
  • Phone: 406-317-3115
  • Fax:
Mailing address:
  • Phone: 406-317-3115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number47167
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number47167
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26978
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD46039
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: