Provider Demographics
NPI:1013228295
Name:MATLOCK, WILLIAM BLAKE (MSPT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BLAKE
Last Name:MATLOCK
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0072
Mailing Address - Country:US
Mailing Address - Phone:541-390-0523
Mailing Address - Fax:541-787-4383
Practice Address - Street 1:1693 SW CHANDLER AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3236
Practice Address - Country:US
Practice Address - Phone:541-390-0523
Practice Address - Fax:541-787-4383
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist