Provider Demographics
NPI:1083000442
Name:WALERYSIAK, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WALERYSIAK
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 1:2 KEEWAYDIN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-2839
Mailing Address - Country:US
Mailing Address - Phone:800-995-2673
Mailing Address - Fax:
Practice Address - Street 1:2 KEEWAYDIN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-2839
Practice Address - Country:US
Practice Address - Phone:800-995-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02224224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant