Provider Demographics
NPI:1831542240
Name:TRAVELING AGE
Entity type:Organization
Organization Name:TRAVELING AGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:
Authorized Official - First Name:TAKEITHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOYE
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:267-902-7537
Mailing Address - Street 1:10842 GREEN LAKE ST
Mailing Address - Street 2:LOT #93
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-4240
Mailing Address - Country:US
Mailing Address - Phone:267-902-7537
Mailing Address - Fax:
Practice Address - Street 1:901 NE LOOP 410
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1305
Practice Address - Country:US
Practice Address - Phone:267-902-7537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2115702251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health