Healthcare Provider Details

I. General information

NPI: 1194882159
Provider Name (Legal Business Name): TRAVIS ROBERT WYCOFF OTR ,L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 MALCOLM DR SUITE 306
WESTMINSTER MD
21157-6115
US

IV. Provider business mailing address

5 SARA LN
HANOVER PA
17331-8673
US

V. Phone/Fax

Practice location:
  • Phone: 410-876-0706
  • Fax: 410-876-0131
Mailing address:
  • Phone: 717-637-6264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number05499
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: