Provider Demographics
NPI:1154751717
Name:BREAZEALE, TRAVIS (PT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BREAZEALE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 COMMON ST STE 307
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-3566
Mailing Address - Country:US
Mailing Address - Phone:830-625-7130
Mailing Address - Fax:830-625-3228
Practice Address - Street 1:1330 BOILING SPRINGS RD STE 1600
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-4219
Practice Address - Country:US
Practice Address - Phone:803-732-5887
Practice Address - Fax:803-732-5997
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1236842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist