Provider Demographics
NPI:1801662143
Name:SIRA, TRAVIS WALTER (LAC, LMT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WALTER
Last Name:SIRA
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 PLANTERS RETREAT
Mailing Address - Street 2:
Mailing Address - City:EDISTO ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29438-6987
Mailing Address - Country:US
Mailing Address - Phone:854-844-3251
Mailing Address - Fax:
Practice Address - Street 1:74 PLANTERS RETREAT
Practice Address - Street 2:
Practice Address - City:EDISTO ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29438-6987
Practice Address - Country:US
Practice Address - Phone:854-844-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65.000379171100000X
OH33.021313225700000X
SC13236225700000X
SC406171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist