Provider Demographics
NPI:1508909078
Name:PROUTY, MATTHEW S (LIC AC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:PROUTY
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 PALFREY ST
Mailing Address - Street 2:# 2
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4705
Mailing Address - Country:US
Mailing Address - Phone:617-393-1688
Mailing Address - Fax:
Practice Address - Street 1:67 PALFREY ST
Practice Address - Street 2:# 2
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4705
Practice Address - Country:US
Practice Address - Phone:617-393-1688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226520171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist