Provider Demographics
NPI:1720010564
Name:MATTHEWS, GAVIN (PT)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 WICHERS DR
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3064
Mailing Address - Country:US
Mailing Address - Phone:504-347-5421
Mailing Address - Fax:504-378-9331
Practice Address - Street 1:2600 BELLE CHASSE HWY
Practice Address - Street 2:SUITE 208
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-7156
Practice Address - Country:US
Practice Address - Phone:504-433-8744
Practice Address - Fax:504-433-8740
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03245PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPT03245OtherPT LICENSE NUMBER