1063138352 NPI number — TRAVIS JAY SLAGOWSKI BA, MA, LPC-2085

Table of content: TRAVIS JAY SLAGOWSKI BA, MA, LPC-2085 (NPI 1063138352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063138352 NPI number — TRAVIS JAY SLAGOWSKI BA, MA, LPC-2085

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLAGOWSKI
Provider First Name:
TRAVIS
Provider Middle Name:
JAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BA, MA, LPC-2085
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063138352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST STEPHENS
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82524-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-856-0470
Provider Business Mailing Address Fax Number:
307-463-4477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 GREAT PLAINS ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARAPAHOE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82510-8251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-856-0470
Provider Business Practice Location Address Fax Number:
307-463-4254
Provider Enumeration Date:
10/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC-2085 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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