Provider Demographics
NPI:1558719963
Name:MATTHEWSON, KYLE (ATC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MATTHEWSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 ESSEN PL
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3457
Mailing Address - Country:US
Mailing Address - Phone:740-590-2916
Mailing Address - Fax:
Practice Address - Street 1:100 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-1100
Practice Address - Country:US
Practice Address - Phone:740-587-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT002638171000000X
OHAT0045662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No171000000XOther Service ProvidersMilitary Health Care Provider