Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 110520 | TX |
NPI | 1477195402 |
---|---|
Provider Name | Christopher Michael Travis |
First Address | Longview, TX 75605-3139 |
Second Address | Longview, TX 75605-3139 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2019 |
Last Update Date | 10/10/2019 |