Basic Information
| Provider Information | |||||||||
| NPI: | 1003371907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERRERO | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | LLBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8415 SHIRLEY CT APT 11 | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490244764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692459455 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2615 STADIUM DR | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490081654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693431651 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 6802090246 | MI | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.