Provider Demographics
NPI:1245735232
Name:MATUG, AGNES (OT ASSISTANT)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:MATUG
Suffix:
Gender:F
Credentials:OT ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WILCOX AVE
Mailing Address - Street 2:
Mailing Address - City:EAST BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06023-1010
Mailing Address - Country:US
Mailing Address - Phone:860-810-5487
Mailing Address - Fax:
Practice Address - Street 1:44 WILCOX AVE
Practice Address - Street 2:
Practice Address - City:EAST BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06023-1010
Practice Address - Country:US
Practice Address - Phone:860-829-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001397224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant