Provider Demographics
NPI:1346542768
Name:DUHAMEL, MATTHEW MARCELLO
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MARCELLO
Last Name:DUHAMEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 NORTHDALE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3028
Mailing Address - Country:US
Mailing Address - Phone:763-754-7072
Mailing Address - Fax:763-754-7077
Practice Address - Street 1:2104 NORTHDALE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3028
Practice Address - Country:US
Practice Address - Phone:763-754-7072
Practice Address - Fax:763-754-7077
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8581225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist