Provider Demographics
NPI:1578751210
Name:THOMLEY, TRAVIS (HIS)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:THOMLEY
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 STATE ROAD 136
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9232
Mailing Address - Country:US
Mailing Address - Phone:608-355-0555
Mailing Address - Fax:
Practice Address - Street 1:622 STATE ROAD 136
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9232
Practice Address - Country:US
Practice Address - Phone:608-355-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1269-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42839300Medicaid