Provider Demographics
NPI:1790708469
Name:RICKETSON, MATTHEW (OT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RICKETSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 TOUISSET AVE.
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-5347
Mailing Address - Country:US
Mailing Address - Phone:401-339-0086
Mailing Address - Fax:401-728-3920
Practice Address - Street 1:588 PAWTUCKET AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-722-2400
Practice Address - Fax:401-728-3920
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT00910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI679003271Medicare ID - Type Unspecified