Provider Demographics
NPI:1790802221
Name:SELLERS, MATT W (PT)
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:W
Last Name:SELLERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 ALMOND CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5005
Mailing Address - Country:US
Mailing Address - Phone:415-479-2928
Mailing Address - Fax:
Practice Address - Street 1:165 N REDWOOD DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1969
Practice Address - Country:US
Practice Address - Phone:415-499-0278
Practice Address - Fax:415-499-0297
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27124174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist