Provider Demographics
NPI:1114296597
Name:MATTHEW, IFEANYI (OTA)
Entity Type:Individual
Prefix:
First Name:IFEANYI
Middle Name:
Last Name:MATTHEW
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 BRUNER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3403
Mailing Address - Country:US
Mailing Address - Phone:718-379-9820
Mailing Address - Fax:
Practice Address - Street 1:1156 N BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1108
Practice Address - Country:US
Practice Address - Phone:914-965-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007024224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant