Provider Demographics
NPI:1235421256
Name:LONG, TRAVIS KYLE (ATC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:KYLE
Last Name:LONG
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1110 N LEE AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2612
Mailing Address - Country:US
Mailing Address - Phone:405-230-9000
Mailing Address - Fax:405-230-9175
Practice Address - Street 1:4901 W RENO AVE
Practice Address - Street 2:STE 500
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6346
Practice Address - Country:US
Practice Address - Phone:405-230-9290
Practice Address - Fax:405-230-9284
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK6082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer