Provider Demographics
NPI:1386682615
Name:MATUSZEK, MYRA ANN (PT)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:ANN
Last Name:MATUSZEK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:ANN
Other - Last Name:BROUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:2230 TOWNE LAKE PKWY
Practice Address - Street 2:BLDG. 1200, SUITES 100 &110
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5540
Practice Address - Country:US
Practice Address - Phone:770-926-2744
Practice Address - Fax:770-926-2794
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4895Medicare ID - Type UnspecifiedGROUP NUMBER