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General NPI Number Information
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NPI Number | 1881101020
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Entity Type | Individual
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Provider Name | KENYETTA ROSE TRAVIS
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Gender | Female
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Dates
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Enumeration Date | 01/09/2018
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Last Update Date | 01/09/2018
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Provider Practice Location Address
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Address Line | 4200 REGENT ST STE 250
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City | COLUMBUS
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State | OH
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Zip | 43219-6229
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Country | US
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Telephone | 614-420-2268
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Fax |
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Provider Business Mailing Address
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Address Line | 4177 WESTERVILLE RD
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City | COLUMBUS
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State | OH
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Zip | 43224-1867
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Country | US
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Telephone | 614-330-0647
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | S0030578
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License Number State | OH
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