Provider Demographics
NPI:1740056910
Name:ROBERTS, TRAVIS R (LMT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:R
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29527-6031
Mailing Address - Country:US
Mailing Address - Phone:757-375-8560
Mailing Address - Fax:
Practice Address - Street 1:1311 13TH AVE UNIT F
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3668
Practice Address - Country:US
Practice Address - Phone:843-855-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12853225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist