MEDICARE: TRAVIS DAVID WENTWORTH LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		IA

General Provider Information

NPI Number	:	1053063305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS DAVID WENTWORTH LMSW

Provider Business Mailing Address
First Line	:	1603 22ND ST STE 200
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-1410
Country	:	US
Telephone Number	:	515-601-0411
Fax Number	:

Provider Business Practice Location Address
First Line	:	1603 22ND ST STE 200
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-1410
Country	:	US
Telephone Number	:	515-601-0411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	01/18/2022

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