Provider Demographics
NPI:1033129853
Name:TYCZ, MATTHEW (MSPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:TYCZ
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 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-828-2449
Mailing Address - Fax:207-828-7850
Practice Address - Street 1:74 BARIBEAU DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3218
Practice Address - Country:US
Practice Address - Phone:207-798-4050
Practice Address - Fax:207-798-4018
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME026502Medicare PIN