Provider Demographics
NPI:1558994756
Name:MATASOVSKY, SHANNON ELIZABETH HITCHCOCK (DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH HITCHCOCK
Last Name:MATASOVSKY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 LENCESTER AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-8813
Mailing Address - Country:US
Mailing Address - Phone:630-484-6425
Mailing Address - Fax:
Practice Address - Street 1:780 COMMUNITY DR UNIT 5
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-2510
Practice Address - Country:US
Practice Address - Phone:319-383-0322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-15
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist