Provider Demographics
NPI:1194325712
Name:BOLSTAD, TRAVIS (DPT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BOLSTAD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45790 216A ST
Mailing Address - Street 2:
Mailing Address - City:VOLGA
Mailing Address - State:SD
Mailing Address - Zip Code:57071-6820
Mailing Address - Country:US
Mailing Address - Phone:605-695-0594
Mailing Address - Fax:
Practice Address - Street 1:400 22ND AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2450
Practice Address - Country:US
Practice Address - Phone:605-697-7336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA097556225100000X
SD2166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist