Provider Demographics
NPI:1427297308
Name:TRAVIS, TANYA PEACOCK (LAC)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:PEACOCK
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3165 COLD HARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-8082
Mailing Address - Country:US
Mailing Address - Phone:843-810-9731
Mailing Address - Fax:843-641-0181
Practice Address - Street 1:3030 ASHLEY TOWN CENTER DR
Practice Address - Street 2:SUITE B-203
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5664
Practice Address - Country:US
Practice Address - Phone:843-735-5900
Practice Address - Fax:843-735-7323
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL 128171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist