Provider Demographics
NPI:1932309374
Name:TRAVIS, MARIANA S (RPT)
Entity Type:Individual
Prefix:MS
First Name:MARIANA
Middle Name:S
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 DILLARD HILL DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-4912
Mailing Address - Country:US
Mailing Address - Phone:864-280-5890
Mailing Address - Fax:864-964-2692
Practice Address - Street 1:1700 S FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29624-3321
Practice Address - Country:US
Practice Address - Phone:864-260-5225
Practice Address - Fax:864-964-2692
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07462251P0200X
TX12041792251P0200X
SC049862251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics