Provider Demographics
NPI:1174945661
Name:TRAVIS, KENDALL TRAE (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:KENDALL
Middle Name:TRAE
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 WYNDHURST DR
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2550
Mailing Address - Country:US
Mailing Address - Phone:434-237-8160
Mailing Address - Fax:434-237-8161
Practice Address - Street 1:801 WYNDHURST DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2550
Practice Address - Country:US
Practice Address - Phone:434-237-8160
Practice Address - Fax:434-237-8161
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305208170Medicaid
VA2305208170Medicare NSC