Provider Demographics
NPI:1669758728
Name:GAGE, MATTHEW JO (PHD, LAT, ATC)
Entity type:Individual
Prefix:PROF
First Name:MATTHEW
Middle Name:JO
Last Name:GAGE
Suffix:
Gender:M
Credentials:PHD, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3552 BRIDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-9269
Mailing Address - Country:US
Mailing Address - Phone:812-237-3961
Mailing Address - Fax:812-237-3615
Practice Address - Street 1:1971 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24515-1903
Practice Address - Country:US
Practice Address - Phone:434-592-3763
Practice Address - Fax:434-582-7261
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260020932255A2300X
IN36001679A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer