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General NPI Number Information
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NPI Number | 1104488105
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Entity Type | Individual
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Provider Name | TRAVIS GORDON
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Gender | Male
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Dates
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Enumeration Date | 07/01/2019
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Last Update Date | 12/22/2021
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Provider Practice Location Address
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Address Line | 4867 E BELTLINE AVE NE BUILDING #1, SUITE 4
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City | GRAND RAPIDS
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State | MI
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Zip | 49525
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Country | US
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Telephone | 616-232-6050
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 E BELTLINE AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-5803
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6451017462
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License Number State | MI
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