Provider Demographics
NPI:1578042347
Name:BRANCHAW, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:BRANCHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 N REED ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5965
Mailing Address - Country:US
Mailing Address - Phone:815-630-8357
Mailing Address - Fax:
Practice Address - Street 1:370 N WEBER RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1392
Practice Address - Country:US
Practice Address - Phone:331-318-3098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-12
Last Update Date:2018-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant