Provider Demographics
NPI:1801358718
Name:RAY, TRAVIS J
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:J
Last Name:RAY
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 1:1212 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:IL
Mailing Address - Zip Code:61252-1003
Mailing Address - Country:US
Mailing Address - Phone:563-613-2179
Mailing Address - Fax:
Practice Address - Street 1:501 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:IL
Practice Address - Zip Code:61085-1444
Practice Address - Country:US
Practice Address - Phone:815-947-2215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006455225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant