Provider Demographics
NPI:1083731285
Name:TRAVIS, TONY (PT)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74700 HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-2924
Mailing Address - Country:US
Mailing Address - Phone:985-863-8595
Mailing Address - Fax:
Practice Address - Street 1:1601 SHORTCUT HWY
Practice Address - Street 2:SUITE B
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-8047
Practice Address - Country:US
Practice Address - Phone:985-641-3818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPTD1525R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist