Provider Demographics
NPI:1417735788
Name:GRYZLO, MATTHEW (COTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GRYZLO
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 WOODBINE RD
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-2263
Mailing Address - Country:US
Mailing Address - Phone:908-246-7604
Mailing Address - Fax:
Practice Address - Street 1:29 WOODBINE RD
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2263
Practice Address - Country:US
Practice Address - Phone:908-246-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09174000224Z00000X
PAOP010186224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant