Provider Demographics
NPI:1306418801
Name:FEOLA, MATTHEW FERDINAND (LMBT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:FERDINAND
Last Name:FEOLA
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 SPRING GARDEN ST APT F
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1900
Mailing Address - Country:US
Mailing Address - Phone:336-493-6513
Mailing Address - Fax:
Practice Address - Street 1:2911 SPRING GARDEN ST APT F
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1900
Practice Address - Country:US
Practice Address - Phone:336-493-6513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist