Provider Demographics
NPI:1134647456
Name:MATRIX MYOFASCIAL
Entity Type:Organization
Organization Name:MATRIX MYOFASCIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF THERAPIST & CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:NATHANIEL
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CPMT II, CIMT
Authorized Official - Phone:413-522-0658
Mailing Address - Street 1:678 BERNARDSTON RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-1104
Mailing Address - Country:US
Mailing Address - Phone:413-522-0658
Mailing Address - Fax:
Practice Address - Street 1:187 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9521
Practice Address - Country:US
Practice Address - Phone:413-522-0658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9911-MT-MT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty