Provider Demographics
NPI:1104570027
Name:THERIOT, TRAVIS EDWARD (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:EDWARD
Last Name:THERIOT
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 IMPERIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5362
Mailing Address - Country:US
Mailing Address - Phone:337-329-3923
Mailing Address - Fax:
Practice Address - Street 1:1747 IMPERIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5362
Practice Address - Country:US
Practice Address - Phone:337-721-7236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.2003012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer