Provider Demographics
NPI:1336975150
Name:MCGREGOR, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MCGREGOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6123 GREEN BAY RD STE 140
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2927
Mailing Address - Country:US
Mailing Address - Phone:262-286-0565
Mailing Address - Fax:
Practice Address - Street 1:6123 GREEN BAY RD STE 140
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2927
Practice Address - Country:US
Practice Address - Phone:262-358-4459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8104-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty