Provider Demographics
NPI:1629698477
Name:AMICK, MATT (PTA, CES)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:AMICK
Suffix:
Gender:M
Credentials:PTA, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 EDGEWATER VLG APT 11
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-3840
Mailing Address - Country:US
Mailing Address - Phone:814-525-9440
Mailing Address - Fax:
Practice Address - Street 1:97 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-3137
Practice Address - Country:US
Practice Address - Phone:724-437-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI005702225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant