Provider Demographics
NPI:1790265528
Name:MATLOCK, BRAD ALAN
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:ALAN
Last Name:MATLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 S FM 51 STE 103
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3644
Mailing Address - Country:US
Mailing Address - Phone:940-627-6976
Mailing Address - Fax:940-627-3491
Practice Address - Street 1:1713 S FM 51 STE 103
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3644
Practice Address - Country:US
Practice Address - Phone:940-627-6976
Practice Address - Fax:940-627-3491
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11519232251S0007X, 2251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics