Provider Demographics
NPI:1699019133
Name:CRAIG, TRAVIS BLAKE (DPT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:BLAKE
Last Name:CRAIG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25305 ARROYO CT
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-7916
Mailing Address - Country:US
Mailing Address - Phone:208-863-1618
Mailing Address - Fax:
Practice Address - Street 1:25305 ARROYO CT
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-7916
Practice Address - Country:US
Practice Address - Phone:208-863-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist