Healthcare Provider Details

I. General information

NPI: 1386691632
Provider Name (Legal Business Name): TRAVIS DALE HODGSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 GOODMAN RD SUITE I
OLIVE BRANCH MS
38654
US

IV. Provider business mailing address

9100 CHAMPLAIN DR
OLIVE BRANCH MS
38654
US

V. Phone/Fax

Practice location:
  • Phone: 662-890-3382
  • Fax: 662-890-3385
Mailing address:
  • Phone: 662-893-7570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA3566
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: