Provider Demographics
NPI:1912674144
Name:TRAVIS, MADISON MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1531
Mailing Address - Country:US
Mailing Address - Phone:608-325-9141
Mailing Address - Fax:
Practice Address - Street 1:516 26TH AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1531
Practice Address - Country:US
Practice Address - Phone:608-325-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3201-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant