Provider Demographics
NPI:1669707568
Name:MATTHIESSEN, ANGELA D (OT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:MATTHIESSEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 DOGWOOD DR S
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-8025
Mailing Address - Country:US
Mailing Address - Phone:770-330-1061
Mailing Address - Fax:
Practice Address - Street 1:402 DOGWOOD DR S
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-8025
Practice Address - Country:US
Practice Address - Phone:770-330-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOY002294225X00000X
SC5534225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC008454699OtherDRIVERS LICENSE