Provider Demographics
NPI:1992520068
Name:FISHER-KING, TRAVIS MICHAEL
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:MICHAEL
Last Name:FISHER-KING
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 1:1441 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1707
Mailing Address - Country:US
Mailing Address - Phone:563-383-1900
Mailing Address - Fax:563-328-5690
Practice Address - Street 1:1441 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-383-1900
Practice Address - Fax:563-328-5690
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA125891104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker