Provider Demographics
NPI:1710364062
Name:YOUNG, TRAVIS (LAC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 11TH ST E
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1938
Mailing Address - Country:US
Mailing Address - Phone:715-556-4189
Mailing Address - Fax:
Practice Address - Street 1:2321 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7003
Practice Address - Country:US
Practice Address - Phone:715-233-7739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI776-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist