Provider Demographics
NPI:1447790613
Name:DEVIVO, MATTHEW A (SLP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:DEVIVO
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 ADAMS AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-1599
Mailing Address - Country:US
Mailing Address - Phone:570-963-1278
Mailing Address - Fax:570-963-1292
Practice Address - Street 1:2010 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-1508
Practice Address - Country:US
Practice Address - Phone:570-963-1278
Practice Address - Fax:570-963-1292
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL013114235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist