Provider Demographics
NPI:1689112807
Name:PERKINS, TRAVIS LANE
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LANE
Last Name:PERKINS
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 1:6127 CLYDE ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-2356
Mailing Address - Country:US
Mailing Address - Phone:713-705-1404
Mailing Address - Fax:
Practice Address - Street 1:3875 HOLMAN ST
Practice Address - Street 2:RM 104
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77204-6015
Practice Address - Country:US
Practice Address - Phone:713-743-9840
Practice Address - Fax:713-743-9860
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer