Healthcare Provider Details

I. General information

NPI: 1952547903
Provider Name (Legal Business Name): MR. TRAVIS VAN DEATON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51960 GUMWOOD RD.
GRANGER IN
46530-7068
US

IV. Provider business mailing address

51960 GUMWOOD RD
GRANGER IN
46530-6207
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-4665
  • Fax:
Mailing address:
  • Phone: 574-247-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number95001774A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: