Provider Demographics
NPI:1629226139
Name:SUMMERVILLE, TRAVIS L (MPT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:L
Last Name:SUMMERVILLE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-3300
Mailing Address - Country:US
Mailing Address - Phone:248-332-8600
Mailing Address - Fax:248-335-9490
Practice Address - Street 1:1298 WALLOON WAY
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360
Practice Address - Country:US
Practice Address - Phone:248-891-0388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008389225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist