Provider Demographics
NPI:1518449586
Name:HERALD, TRAVIS (DPT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:HERALD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4533 BRAMBLETON AVE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3436
Mailing Address - Country:US
Mailing Address - Phone:540-772-8022
Mailing Address - Fax:540-772-0294
Practice Address - Street 1:109 KNOTBREAK RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-5404
Practice Address - Country:US
Practice Address - Phone:540-772-8022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist