Provider Demographics
NPI:1649427261
Name:TRAVIS, SUSAN EDITH (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:EDITH
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E STATE ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5551
Mailing Address - Country:US
Mailing Address - Phone:607-275-0224
Mailing Address - Fax:607-275-0224
Practice Address - Street 1:202 E STATE ST
Practice Address - Street 2:SUITE 402
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5551
Practice Address - Country:US
Practice Address - Phone:607-275-0224
Practice Address - Fax:607-275-0224
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001553133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001553OtherNEW YORK STATE CERTIFICATION
NY718865OtherAMERICAN DIETETIC ASSOCIATION