Provider Demographics
NPI:1205096773
Name:ATENCIO, MATTHEW STEPHEN (PTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:ATENCIO
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 1:3858 PENNSYLVANIA ST APT 55
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-5236
Mailing Address - Country:US
Mailing Address - Phone:360-281-4748
Mailing Address - Fax:360-636-3421
Practice Address - Street 1:1500 3RD AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3229
Practice Address - Country:US
Practice Address - Phone:360-423-8800
Practice Address - Fax:360-636-3421
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8310225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant