Provider Demographics
NPI:1720704216
Name:PROVENCE, MATTHEW PROVENCE (DPT,PT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:PROVENCE
Last Name:PROVENCE
Suffix:
Gender:M
Credentials:DPT,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 OKFUSKI TRL
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-3319
Mailing Address - Country:US
Mailing Address - Phone:912-401-1262
Mailing Address - Fax:
Practice Address - Street 1:464 SAINT LUKES DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7104
Practice Address - Country:US
Practice Address - Phone:334-244-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH11015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist