Provider Demographics
NPI:1033640594
Name:BEARE, MATTHEW (COTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BEARE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 DENNISON PARK LOOP SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-7123
Mailing Address - Country:US
Mailing Address - Phone:505-480-5048
Mailing Address - Fax:
Practice Address - Street 1:717 DENNISON PARK LOOP SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-7123
Practice Address - Country:US
Practice Address - Phone:505-480-5048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-25
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3032224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant