Provider Demographics
NPI:1689176992
Name:BALTZELL, MATTHEW J (PTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:BALTZELL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 OAK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-8901
Mailing Address - Country:US
Mailing Address - Phone:734-998-8600
Mailing Address - Fax:
Practice Address - Street 1:2121 OAK VALLEY DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-8901
Practice Address - Country:US
Practice Address - Phone:734-998-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001160225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant