Healthcare Provider Details

I. General information

NPI: 1285937417
Provider Name (Legal Business Name): MR. TRAVIS R ELY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W WARM SPRINGS RD SUITE 129
HENDERSON NV
89014-7633
US

IV. Provider business mailing address

1481 W WARM SPRINGS RD SUITE 129
HENDERSON NV
89014-7633
US

V. Phone/Fax

Practice location:
  • Phone: 702-547-0201
  • Fax:
Mailing address:
  • Phone: 702-547-0201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number1701895704
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: