Provider Demographics
NPI:1497818140
Name:BOYETTE, TRAVIS RYAN (OTR)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:RYAN
Last Name:BOYETTE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 N 78TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-4640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4016 N 78TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-4640
Practice Address - Country:US
Practice Address - Phone:480-246-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3402225X00000X
MA9576225X00000X
GA2607225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist