Provider Demographics
NPI:1962816447
Name:CASTLEBERRY, TRAVIS (PT)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2618
Mailing Address - Country:US
Mailing Address - Phone:901-221-2619
Mailing Address - Fax:866-380-3102
Practice Address - Street 1:230A MAIN STREET
Practice Address - Street 2:
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38855
Practice Address - Country:US
Practice Address - Phone:662-591-7077
Practice Address - Fax:662-591-7078
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9998225100000X
MSPT6113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist