Provider Demographics
NPI:1063101566
Name:TEETS, TRAVIS (PRSS)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:TEETS
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 HIGH ST STE 307
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-5455
Mailing Address - Country:US
Mailing Address - Phone:304-288-1513
Mailing Address - Fax:
Practice Address - Street 1:206 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-7539
Practice Address - Country:US
Practice Address - Phone:304-288-1513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23-987175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist