Provider Demographics
NPI:1720640493
Name:HAANSTAD, TRAVIS JEFFREY
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JEFFREY
Last Name:HAANSTAD
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 1:3131 MOUNTAIN CREEK RD APT 6C7
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-7252
Mailing Address - Country:US
Mailing Address - Phone:715-581-4601
Mailing Address - Fax:
Practice Address - Street 1:615 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2504
Practice Address - Country:US
Practice Address - Phone:423-425-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer