Provider Demographics
NPI:1558080762
Name:TINDAL, TRAVIS JORDAN III
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JORDAN
Last Name:TINDAL
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:AL
Mailing Address - Zip Code:36054-4212
Mailing Address - Country:US
Mailing Address - Phone:334-290-5095
Mailing Address - Fax:334-625-1853
Practice Address - Street 1:2050 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:AL
Practice Address - Zip Code:36054-4212
Practice Address - Country:US
Practice Address - Phone:334-290-5095
Practice Address - Fax:334-625-1853
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-22-227329106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician