1972029023 NPI number — SEAN TRAVIS LCSW

Table of content: SEAN TRAVIS LCSW (NPI 1972029023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972029023 NPI number — SEAN TRAVIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRAVIS
Provider First Name:
SEAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1972029023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 HIGHLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST BRUNSWICK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08816-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-735-6930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 KINGS HWY E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HADDONFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08033-2015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-735-6930
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2017

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: 1041C0700X , with the licence number:  44SC05890600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: SW134422 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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