Provider Demographics
NPI:1679736680
Name:QUILLER, TRAVIS DUANE (AUD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DUANE
Last Name:QUILLER
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10021 DUPONT CIRCLE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1604
Mailing Address - Country:US
Mailing Address - Phone:260-426-8117
Mailing Address - Fax:260-420-0817
Practice Address - Street 1:10021 DUPONT CIRCLE CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1604
Practice Address - Country:US
Practice Address - Phone:260-426-8117
Practice Address - Fax:260-420-0817
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8628231H00000X, 231HA2400X, 231HA2500X, 237600000X, 237700000X, 235500000X
IN23002847A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300089169Medicaid
TNP00634250OtherMEDICARE RR
TNP00634250OtherMEDICARE RR