Provider Demographics
NPI:1740761139
Name:MCCORD, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MCCORD
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 1:16315 NE 23RD ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-8665
Mailing Address - Country:US
Mailing Address - Phone:360-882-0767
Mailing Address - Fax:360-885-2580
Practice Address - Street 1:16315 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8665
Practice Address - Country:US
Practice Address - Phone:360-882-0767
Practice Address - Fax:360-885-2580
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60817418225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist