Provider Demographics
NPI:1780049841
Name:GOLD, MATTHEW RICHARD (OTR/L)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RICHARD
Last Name:GOLD
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 BROUGHAM DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8001
Mailing Address - Country:US
Mailing Address - Phone:314-479-4573
Mailing Address - Fax:
Practice Address - Street 1:259 BROUGHAM DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8001
Practice Address - Country:US
Practice Address - Phone:314-479-4573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010038836225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist