Provider Demographics
NPI:1750155164
Name:SMITH, MATTHEW LAWRENCE (PTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LAWRENCE
Last Name:SMITH
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 1:5101 S RIO GRANDE ST APT 2-309
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-8257
Mailing Address - Country:US
Mailing Address - Phone:703-389-2365
Mailing Address - Fax:
Practice Address - Street 1:6612 S WARD ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-4855
Practice Address - Country:US
Practice Address - Phone:303-409-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0015413225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant