Provider Demographics
NPI:1093373300
Name:ELLIOTT, TRAVIS (LPTA)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 GABLES DR APT 203
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-4808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1229 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-3131
Practice Address - Country:US
Practice Address - Phone:540-586-7658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-01
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605347225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant