Provider Demographics
NPI:1992287221
Name:BANKS, TRAVIS (OTR/L)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BANKS
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 1:3681 S 2000 E APT 2
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4319
Mailing Address - Country:US
Mailing Address - Phone:435-659-7552
Mailing Address - Fax:
Practice Address - Street 1:1992 W ANTELOPE DR STE 1D
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4974
Practice Address - Country:US
Practice Address - Phone:801-773-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10962470-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist