Provider Demographics
NPI:1821660770
Name:ANDERSON, MATTHEW RAY (PTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RAY
Last Name:ANDERSON
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 1:52465 SANTA MONICA DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9652
Mailing Address - Country:US
Mailing Address - Phone:574-323-3030
Mailing Address - Fax:
Practice Address - Street 1:23770 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-9699
Practice Address - Country:US
Practice Address - Phone:269-445-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002547225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502002547OtherPTA LICENSE #