Provider Demographics
NPI:1770969289
Name:CECILIO, MATTHEW (COTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:CECILIO
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 LOUISE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND FURNACE
Mailing Address - State:TN
Mailing Address - Zip Code:37051-9088
Mailing Address - Country:US
Mailing Address - Phone:703-851-6715
Mailing Address - Fax:
Practice Address - Street 1:298 WARFIELD BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-1828
Practice Address - Country:US
Practice Address - Phone:931-906-0440
Practice Address - Fax:931-920-5070
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA0000002508224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant