MEDICARE: MR. TRAVIS LANE MATHIAS LICSW

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	104100000X	Social Worker	086397	IA
2	1041C0700X	Clinical Social Worker	28792	MN

General Provider Information

NPI Number	:	1841706967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRAVIS LANE MATHIAS LICSW

Provider Business Mailing Address
First Line	:	825 NICOLLET MALL STE 1455
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2703
Country	:	US
Telephone Number	:	612-345-5194
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 NICOLLET MALL STE 1455
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55402-2703
Country	:	US
Telephone Number	:	612-293-0594
Fax Number	:	612-354-7974

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

Provider Enumeration Date	:	12/27/2017
Last Update Date	:	08/03/2022

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