Provider Demographics
NPI:1336280361
Name:GREEN, TRAVIS (ATR)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8919 JANERO AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-3419
Mailing Address - Country:US
Mailing Address - Phone:651-214-4593
Mailing Address - Fax:
Practice Address - Street 1:5595 MEMORIAL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-1091
Practice Address - Country:US
Practice Address - Phone:651-439-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer