Healthcare Provider Details

I. General information

NPI: 1609199843
Provider Name (Legal Business Name): TRAVIS F WINTER LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WARREN RD
ITHACA NY
14850-1862
US

IV. Provider business mailing address

555 WARREN RD
ITHACA NY
14850-1862
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-1555
  • Fax: 607-257-2510
Mailing address:
  • Phone: 607-257-1555
  • Fax: 607-257-2510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR057294
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: