Provider Demographics
NPI:1467602979
Name:BALD, MATTHEW JOHN (COTA/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:BALD
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S 3RD ST
Mailing Address - Street 2:APT C
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3341
Mailing Address - Country:US
Mailing Address - Phone:412-403-3584
Mailing Address - Fax:
Practice Address - Street 1:43 CHURCH LN
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-2503
Practice Address - Country:US
Practice Address - Phone:610-356-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP003374L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant