Provider Demographics
NPI:1093744252
Name:THAUT, MATTHEW MARK (OTR/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MARK
Last Name:THAUT
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 COLBY AVE
Mailing Address - Street 2:APT. 202
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4342
Mailing Address - Country:US
Mailing Address - Phone:425-257-1336
Mailing Address - Fax:
Practice Address - Street 1:916 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4147
Practice Address - Country:US
Practice Address - Phone:425-258-7600
Practice Address - Fax:425-258-7406
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003736225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist