Provider Demographics
NPI:1699183962
Name:MINNIEAR, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MINNIEAR
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 1:909 DAVIS ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3683
Mailing Address - Country:US
Mailing Address - Phone:847-733-7906
Mailing Address - Fax:847-733-8405
Practice Address - Street 1:909 DAVIS ST
Practice Address - Street 2:SUITE 220
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3683
Practice Address - Country:US
Practice Address - Phone:847-733-7906
Practice Address - Fax:847-733-8405
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist