Provider Demographics
NPI:1538599006
Name:SMITH, TRAVIS MARK (LLBSW)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:MARK
Last Name:SMITH
Suffix:
Gender:M
Credentials:LLBSW
Other - Prefix:MR
Other - First Name:TRAVIS
Other - Middle Name:MARK
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LLBSW
Mailing Address - Street 1:1800 W BIG BEAVER RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3535
Mailing Address - Country:US
Mailing Address - Phone:248-918-5600
Mailing Address - Fax:
Practice Address - Street 1:1800 W BIG BEAVER RD STE 150
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3535
Practice Address - Country:US
Practice Address - Phone:248-918-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087942104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI171M00000XMedicaid