Provider Demographics
NPI:1164679072
Name:TRAVIS, AMANDA MICHELLE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELLE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 DEXTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:GILBERTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42044
Mailing Address - Country:US
Mailing Address - Phone:270-339-4670
Mailing Address - Fax:
Practice Address - Street 1:10456 US HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029
Practice Address - Country:US
Practice Address - Phone:270-339-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02143225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant