Provider Demographics
NPI:1477872950
Name:DEWALD, MATTHEW LEE (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:DEWALD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 W 38TH AVE
Mailing Address - Street 2:106B
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4300
Mailing Address - Country:US
Mailing Address - Phone:303-953-3163
Mailing Address - Fax:202-245-0726
Practice Address - Street 1:8550 W 38TH AVE
Practice Address - Street 2:106B
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4300
Practice Address - Country:US
Practice Address - Phone:303-953-3163
Practice Address - Fax:202-245-0726
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0665463Medicaid
IA0665463Medicaid