Provider Demographics
NPI:1497256283
Name:WUTKE, MATTHEW JAMES (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:WUTKE
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 1:26850 PROVIDENCE PKWY STE 163
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1254
Mailing Address - Country:US
Mailing Address - Phone:248-465-4728
Mailing Address - Fax:
Practice Address - Street 1:26850 PROVIDENCE PKWY STE 163
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1254
Practice Address - Country:US
Practice Address - Phone:248-465-4728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist