Provider Demographics
NPI:1477750578
Name:SHIRLEY, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1306
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-1306
Mailing Address - Country:US
Mailing Address - Phone:618-255-9601
Mailing Address - Fax:318-255-7591
Practice Address - Street 1:1817 NORTHPOINTE LANE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3879
Practice Address - Country:US
Practice Address - Phone:318-255-9601
Practice Address - Fax:318-255-7591
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG5096OtherBCBS