Provider Demographics
NPI:1194397893
Name:MATTINA, TAYLOR TUBERTINI (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:TUBERTINI
Last Name:MATTINA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:TUBERTINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:980 COURTHOUSE RD APT 924
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-4288
Mailing Address - Country:US
Mailing Address - Phone:228-324-0264
Mailing Address - Fax:
Practice Address - Street 1:12449 US 49
Practice Address - Street 2:SUITE C
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3950
Practice Address - Country:US
Practice Address - Phone:228-872-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT-7129208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation