Provider Demographics
NPI:1053854414
Name:METZGER, MATTHEW (OT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:METZGER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 JACKSON DR
Mailing Address - Street 2:
Mailing Address - City:MONESSEN
Mailing Address - State:PA
Mailing Address - Zip Code:15062-2501
Mailing Address - Country:US
Mailing Address - Phone:724-454-5668
Mailing Address - Fax:
Practice Address - Street 1:4355 PHEASANT RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-5272
Practice Address - Country:US
Practice Address - Phone:540-725-5368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC014834225X00000X
CAOT18120225X00000X
IN31006597A225X00000X
VA0119-007727225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053854414Medicaid