MEDICARE: MR. TRAVIS SUTTON LPC

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	101YP2500X	Professional Counselor	178021273	IL
2	101YS0200X	School Counselor	4127755	AK
3	101YS0200X	School Counselor	3590002754	WI
4	101YP2500X	Professional Counselor	0011	MP

General Provider Information

NPI Number	:	1447065198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRAVIS SUTTON LPC

Provider Business Mailing Address
First Line	:	3740 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5653
Country	:	US
Telephone Number	:	773-560-1829
Fax Number	:

Provider Business Practice Location Address
First Line	:	3740 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5653
Country	:	US
Telephone Number	:	773-560-1829
Fax Number	:

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

Provider Enumeration Date	:	02/10/2025
Last Update Date	:	06/12/2025

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