Provider Demographics
NPI:1629054697
Name:BRETON, MATTHEW RICHARD (PT,MPT,OCS,CSCS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RICHARD
Last Name:BRETON
Suffix:
Gender:M
Credentials:PT,MPT,OCS,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-1346
Mailing Address - Country:US
Mailing Address - Phone:802-626-4224
Mailing Address - Fax:802-626-5042
Practice Address - Street 1:31 MIDDLE STREET
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851
Practice Address - Country:US
Practice Address - Phone:802-626-4224
Practice Address - Fax:802-626-5042
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0003564225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN
VTVAD000Medicare UPIN