MEDICARE: TOR TRAVIS LCSW

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	SWB-2023-0057	NM
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1720601990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOR TRAVIS LCSW

Provider Business Mailing Address
First Line	:	132 ARROYO HONDO RD
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87508-5941
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 LENA ST STE C
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-3891
Country	:	US
Telephone Number	:	971-261-8737
Fax Number	:	505-796-5112

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

Provider Enumeration Date	:	05/22/2020
Last Update Date	:	11/18/2025

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