Provider Demographics
NPI:1790068021
Name:BOERSMA, TRAVIS DANIEL (DPT)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:DANIEL
Last Name:BOERSMA
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 1:2585 LYNWOOD PL
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4163
Mailing Address - Country:US
Mailing Address - Phone:954-325-9395
Mailing Address - Fax:844-210-9901
Practice Address - Street 1:2425 N COURTENAY PKWY STE 103
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4181
Practice Address - Country:US
Practice Address - Phone:954-325-9395
Practice Address - Fax:844-210-9901
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 26481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL726167Medicaid