Provider Demographics
NPI:1467042903
Name:TRAVIS, MARVIN DEWAN (BS ED ESE)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:DEWAN
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:BS ED ESE
Other - Prefix:
Other - First Name:MARVIN
Other - Middle Name:DEWAN
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:43825 MICHIGAN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2551
Mailing Address - Country:US
Mailing Address - Phone:734-713-0080
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE STE 2
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:734-713-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health