Provider Demographics
NPI:1790368793
Name:WALCZAK, MATTHEW A (OTR/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:WALCZAK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 GRAND AVE S APT 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-3490
Mailing Address - Country:US
Mailing Address - Phone:608-658-5833
Mailing Address - Fax:
Practice Address - Street 1:150 COBBLESTONE LN
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4578
Practice Address - Country:US
Practice Address - Phone:952-892-2717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106212225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist