Provider Demographics
NPI:1104537406
Name:TRAVIS, CARLENE
Entity type:Individual
Prefix:
First Name:CARLENE
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 COTTAGE WAY STE G2
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1474
Mailing Address - Country:US
Mailing Address - Phone:888-204-5762
Mailing Address - Fax:
Practice Address - Street 1:9219 RAINBOW CREEK WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-4814
Practice Address - Country:US
Practice Address - Phone:916-289-0659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2022252916891224ZR0403X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantDriving and Community Mobility