Provider Demographics
NPI:1225295777
Name:TRAVIS, CAROLYN A (PTA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
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 1:1115 NE KEYES RD APT D1
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-7360
Mailing Address - Country:US
Mailing Address - Phone:360-944-6869
Mailing Address - Fax:
Practice Address - Street 1:12607 SE MILL PLAIN BLVD
Practice Address - Street 2:MODULE F
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6055
Practice Address - Country:US
Practice Address - Phone:360-944-2813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7467225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant