Provider Demographics
NPI:1972490043
Name:HAASE, TRAVON
Entity type:Individual
Prefix:
First Name:TRAVON
Middle Name:
Last Name:HAASE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12726 PACIFIC AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4240
Mailing Address - Country:US
Mailing Address - Phone:310-907-6725
Mailing Address - Fax:
Practice Address - Street 1:12726 PACIFIC AVE APT 7
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-4240
Practice Address - Country:US
Practice Address - Phone:310-907-6725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-21
Last Update Date:2025-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17757-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist