Provider Demographics
NPI:1184303661
Name:CARMODY, MATTHEW (PT, DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CARMODY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:CARMODY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:900 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MN
Mailing Address - Zip Code:56256-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 2ND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MN
Practice Address - Zip Code:56256-1006
Practice Address - Country:US
Practice Address - Phone:320-698-7162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1833225100000X
MN9951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist