Provider Demographics
NPI:1104494079
Name:TRAVIS, BILLY CHARLES
Entity type:Individual
Prefix:
First Name:BILLY
Middle Name:CHARLES
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 CITY LGTS
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-5958
Mailing Address - Country:US
Mailing Address - Phone:832-439-3889
Mailing Address - Fax:
Practice Address - Street 1:948 CITY LGTS
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-5958
Practice Address - Country:US
Practice Address - Phone:832-439-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist