Provider Demographics
NPI:1558948596
Name:OPANASENKO, MATTHEW LEE (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:OPANASENKO
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 1:1608 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-4034
Mailing Address - Country:US
Mailing Address - Phone:989-413-2488
Mailing Address - Fax:
Practice Address - Street 1:4304 PAGE AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1078
Practice Address - Country:US
Practice Address - Phone:517-205-7586
Practice Address - Fax:517-205-0110
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019224225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist