Provider Demographics
NPI:1194882159
Name:WYCOFF, TRAVIS ROBERT (OTR ,L)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:ROBERT
Last Name:WYCOFF
Suffix:
Gender:M
Credentials:OTR ,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SARA LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-8673
Mailing Address - Country:US
Mailing Address - Phone:717-637-6264
Mailing Address - Fax:
Practice Address - Street 1:412 MALCOLM DR
Practice Address - Street 2:SUITE 306
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6115
Practice Address - Country:US
Practice Address - Phone:410-876-0706
Practice Address - Fax:410-876-0131
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05499225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4761-0202OtherBLUECHOICE
MD023348001Medicaid
MD7005727OtherAETNA
MD88398001OtherBCBS
MD023348001Medicaid