Provider Demographics
NPI:1659413532
Name:MATOS-BRENNEN, GRACE R (PT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:R
Last Name:MATOS-BRENNEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:R
Other - Last Name:MATOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0726
Mailing Address - Country:US
Mailing Address - Phone:631-474-3652
Mailing Address - Fax:631-474-7893
Practice Address - Street 1:1227-7 MONTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769
Practice Address - Country:US
Practice Address - Phone:631-218-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY57292251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics