Provider Demographics
NPI:1134516800
Name:BRYCE-TRAVIS, MARY (MOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:BRYCE-TRAVIS
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:710 SUNNINGDALE CV
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4301
Mailing Address - Country:US
Mailing Address - Phone:850-225-5676
Mailing Address - Fax:
Practice Address - Street 1:220 EGLIN PKWY SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5899
Practice Address - Country:US
Practice Address - Phone:850-200-4348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 16916225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist