Provider Demographics
NPI:1619141116
Name:COTHREN, TRAVIS J
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:COTHREN
Suffix:
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 1:2175 JACKSON HWY
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4409
Mailing Address - Country:US
Mailing Address - Phone:360-740-1790
Mailing Address - Fax:
Practice Address - Street 1:2175 JACKSON HWY
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4409
Practice Address - Country:US
Practice Address - Phone:360-740-1790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024122225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist