Provider Demographics
NPI:1376966507
Name:WISWESSER, MATTHEW (ATC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:WISWESSER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-3421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:256 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ROCHELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07662-3421
Practice Address - Country:US
Practice Address - Phone:201-519-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001656002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer