Provider Demographics
NPI:1184786618
Name:SPADER, TRAVIS (MSPT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:SPADER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 DUNKLE RD
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-4352
Mailing Address - Country:US
Mailing Address - Phone:732-714-0760
Mailing Address - Fax:732-223-6409
Practice Address - Street 1:2516 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1925
Practice Address - Country:US
Practice Address - Phone:732-223-6309
Practice Address - Fax:732-223-6409
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA09362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ061417RLOMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER