Healthcare Provider Details

I. General information

NPI: 1326493651
Provider Name (Legal Business Name): TRAVIS SPENCER LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2016
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W 500 S STE 9
VERNAL UT
84078-2912
US

IV. Provider business mailing address

1140 W 500 S STE 9
VERNAL UT
84078-2912
US

V. Phone/Fax

Practice location:
  • Phone: 435-789-6300
  • Fax:
Mailing address:
  • Phone: 435-789-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: