Provider Demographics
NPI:1861765398
Name:CLARK, TRAVIS (HAS)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E NORTH BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4114
Mailing Address - Country:US
Mailing Address - Phone:614-263-5151
Mailing Address - Fax:614-263-5365
Practice Address - Street 1:510 E NORTH BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-4114
Practice Address - Country:US
Practice Address - Phone:614-263-5151
Practice Address - Fax:614-263-5365
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHIL02725237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHIL02725OtherSTATE LICENSE