Provider Demographics
NPI:1245867498
Name:LINEBERRY, MATT (PTA)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:LINEBERRY
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 1:905 COLLINWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-3859
Mailing Address - Country:US
Mailing Address - Phone:931-332-1700
Mailing Address - Fax:
Practice Address - Street 1:905 COLLINWOOD HWY
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-3859
Practice Address - Country:US
Practice Address - Phone:931-332-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6813OtherPHYSICAL THERAPIST ASSISTANT