Provider Demographics
NPI:1821652405
Name:MCINTYRE, MATTHEW (MOT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MCINTYRE
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 E TARPON DR STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4195 WESTBERG RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-2950
Practice Address - Country:US
Practice Address - Phone:218-216-9921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105959225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist