Provider Demographics
NPI:1760640213
Name:BLIEVERNICHT, MATTHEW STEVEN (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEVEN
Last Name:BLIEVERNICHT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N15W28300 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-4800
Mailing Address - Country:US
Mailing Address - Phone:262-303-5055
Mailing Address - Fax:262-303-5057
Practice Address - Street 1:N15W28300 GOLF RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-4800
Practice Address - Country:US
Practice Address - Phone:262-303-5055
Practice Address - Fax:262-303-5057
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5973225100000X
WI11016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100257659Medicaid
OR0252231OtherWASHINGTON L&I
OR500609437Medicaid
ORP00802449OtherRR MEDICARE
ORR157901Medicare PIN