| Doctor Name: | MR. TRAVIS JOHN VANDERLIST |
| NPI Number: | 1003155219 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LMSW |
| License Number: | 6801090423 |
| Business Practice Address: | 1500 Weiss St Saginaw, MI - 486025251 |
| Business Phone Number: | 9894972500 |
| Business Fax Number: | 9893214922 |
| Mailing Address: | 311 Oxford Rd, EAST LANSING |
| State: | MI |
| Postal Code: | 488232628 |
| Phone Number: | 5173033969 |
| Fax Number: | |
| NPI Enumeration Date: | 02/07/2013 |
| NPI Last Update Date: | 02/07/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 6801090423 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |