Provider Demographics
NPI:1285339028
Name:GILBERT, TRAVIS SHADE (OTA)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:SHADE
Last Name:GILBERT
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4928 LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-6727
Mailing Address - Country:US
Mailing Address - Phone:214-681-3424
Mailing Address - Fax:
Practice Address - Street 1:3724 JFK BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8260
Practice Address - Country:US
Practice Address - Phone:501-615-8563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A928224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant