Provider Demographics
NPI:1003467010
Name:REA, CODY MATTHEW
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:MATTHEW
Last Name:REA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ANNA SPEAKMAN RD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-2245
Mailing Address - Country:US
Mailing Address - Phone:443-945-5868
Mailing Address - Fax:
Practice Address - Street 1:4201 (201-202) ESTATE RUBY
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTEAD
Practice Address - State:VI
Practice Address - Zip Code:00820
Practice Address - Country:US
Practice Address - Phone:340-718-2665
Practice Address - Fax:340-718-2611
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5198225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant