Provider Demographics
NPI:1730475260
Name:MAILLOUX, MATTHEW A (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:MAILLOUX
Suffix:
Gender:M
Credentials:PT, DPT, OCS
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 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:7493 RIGHT FLANK RD STE 410
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-3846
Practice Address - Country:US
Practice Address - Phone:804-569-7091
Practice Address - Fax:804-569-7094
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1730475260Medicaid
VA225579OtherBCBS (PHYSICAL THERAPY)
VAC05954Medicare PIN
VA1730475260Medicaid