Provider Demographics
NPI:1922416767
Name:SIENKOWSKI, MATTHEW CHRISTOPHER (MS, AT, ATC, OTC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHRISTOPHER
Last Name:SIENKOWSKI
Suffix:
Gender:M
Credentials:MS, AT, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3796 BLACKHAWK DR SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-267-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010016552255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer