Provider Demographics
NPI:1215724463
Name:TENNANT, TRAVIS NATHAN (LLMSW)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:NATHAN
Last Name:TENNANT
Suffix:
Gender:
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4534
Mailing Address - Country:US
Mailing Address - Phone:269-348-2579
Mailing Address - Fax:
Practice Address - Street 1:9594 N 40TH ST
Practice Address - Street 2:
Practice Address - City:HICKORY CORNERS
Practice Address - State:MI
Practice Address - Zip Code:49060-9327
Practice Address - Country:US
Practice Address - Phone:269-548-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511184021041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool