Provider Demographics
NPI:1235263591
Name:FAILLA, MATHEW J (MPT)
Entity Type:Individual
Prefix:MR
First Name:MATHEW
Middle Name:J
Last Name:FAILLA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 VILLAGE CIR
Mailing Address - Street 2:APT C
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-4904
Mailing Address - Country:US
Mailing Address - Phone:337-764-9151
Mailing Address - Fax:
Practice Address - Street 1:053 MCKINLY LAB
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19716
Practice Address - Country:US
Practice Address - Phone:302-831-8893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07164225100000X
DEJ1-00026602251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist