Provider Demographics
NPI:1942595426
Name:MALTBIE, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:MALTBIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 COUNTY ROAD 837
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-7962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1668 COUNTY ROAD 837
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-7962
Practice Address - Country:US
Practice Address - Phone:256-558-6968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5135225200000X
SC2628225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant