Provider Demographics
NPI:1497152862
Name:MCLEOD, MATTHEW (AT, ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MCLEOD
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3279 S OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-9287
Mailing Address - Country:US
Mailing Address - Phone:906-748-0955
Mailing Address - Fax:
Practice Address - Street 1:2472 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3768
Practice Address - Country:US
Practice Address - Phone:906-635-4426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010002382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer