Provider Demographics
NPI:1487246559
Name:DUDLEY, TRAVIS (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 W LINE ST UNIT 491
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93515-7032
Mailing Address - Country:US
Mailing Address - Phone:858-248-6046
Mailing Address - Fax:
Practice Address - Street 1:162 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3415
Practice Address - Country:US
Practice Address - Phone:760-872-2942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT21664225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist