Basic Information
| Provider Information | |||||||||
| NPI: | 1518449586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERALD | ||||||||
| FirstName: | TRAVIS | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4533 BRAMBLETON AVE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240183436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
| FaxNumber: | 5407720294 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 KNOTBREAK RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241535404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407728022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2018 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305212191 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.