Provider Demographics
NPI:1972081693
Name:MATTHEWS, ANGELA KAYE (LMT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:KAYE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 W 17TH ST STE 9
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3379
Mailing Address - Country:US
Mailing Address - Phone:865-228-1566
Mailing Address - Fax:
Practice Address - Street 1:840 W 17TH ST STE 9
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3379
Practice Address - Country:US
Practice Address - Phone:865-228-1566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT-21906764225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist