Provider Demographics
NPI:1760644983
Name:TRAVIS, JUSTIN THOMAS (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:TRAVIS
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-1559
Mailing Address - Country:US
Mailing Address - Phone:270-900-4052
Mailing Address - Fax:270-900-4054
Practice Address - Street 1:2624 RING RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9118
Practice Address - Country:US
Practice Address - Phone:270-900-4052
Practice Address - Fax:270-900-4054
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist