Provider Demographics
NPI:1598123853
Name:DEGEORGE, MATTHEW (MS, ATC, LAT, CSCS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DEGEORGE
Suffix:
Gender:M
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4506
Practice Address - Country:US
Practice Address - Phone:781-961-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer