Provider Demographics
NPI:1205425402
Name:WARREN, MATTHEW J
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:WARREN
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 1:129 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-1057
Mailing Address - Country:US
Mailing Address - Phone:985-249-6111
Mailing Address - Fax:985-249-6109
Practice Address - Street 1:129 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-1057
Practice Address - Country:US
Practice Address - Phone:985-249-6111
Practice Address - Fax:985-249-6109
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT09386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist