Provider Demographics
NPI:1790894418
Name:SERLO, MATTHEW C (MPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:SERLO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 441146
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30160-9522
Mailing Address - Country:US
Mailing Address - Phone:678-403-3632
Mailing Address - Fax:678-567-6737
Practice Address - Street 1:236 PONTE VEDRA PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-6619
Practice Address - Country:US
Practice Address - Phone:678-459-3758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19837174400000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist