Provider Demographics
NPI:1790902880
Name:MATTICE, TERRY KEVIN (PTA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:KEVIN
Last Name:MATTICE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 PINE TREE RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6332
Mailing Address - Country:US
Mailing Address - Phone:607-272-9789
Mailing Address - Fax:
Practice Address - Street 1:2230 N TRIPHAMMER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-6513
Practice Address - Country:US
Practice Address - Phone:607-266-5316
Practice Address - Fax:607-266-5353
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0036971225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant