Provider Demographics
NPI:1124636584
Name:TRAVIS, KRISTY (PT, DPT)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13317 DAVIDSON RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8250
Mailing Address - Country:US
Mailing Address - Phone:618-889-8044
Mailing Address - Fax:
Practice Address - Street 1:1237 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3148
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist