Healthcare Provider Details

I. General information

NPI: 1245601772
Provider Name (Legal Business Name): TRAVIS H VANDEBROWN MSW, LCSW, CSAC, ICS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TRAVIS H BROWN

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E WASHINGTON ST STE 2100
WEST BEND WI
53095-2503
US

IV. Provider business mailing address

333 E WASHINGTON ST STE 2100
WEST BEND WI
53095-2503
US

V. Phone/Fax

Practice location:
  • Phone: 262-335-4583
  • Fax:
Mailing address:
  • Phone: 262-335-4583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16017-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number132330-121
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11401-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: