Healthcare Provider Details

I. General information

NPI: 1184197105
Provider Name (Legal Business Name): TRAVIS W. SCOTT MSSA, LISW-S, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 BRYN MAWR DR NE APT C
ALBUQUERQUE NM
87107-4361
US

IV. Provider business mailing address

3708 BRYN MAWR DR NE APT C
ALBUQUERQUE NM
87107-4361
US

V. Phone/Fax

Practice location:
  • Phone: 505-394-8037
  • Fax:
Mailing address:
  • Phone: 505-394-8037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1801390
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: