Provider Demographics
NPI:1780354696
Name:DICERBO, MATTHEW J
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:J
Last Name:DICERBO
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 1:1210 GREEN OAKS LN APT J
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-8325
Mailing Address - Country:US
Mailing Address - Phone:704-451-1403
Mailing Address - Fax:
Practice Address - Street 1:1210 GREEN OAKS LN APT J
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-8325
Practice Address - Country:US
Practice Address - Phone:704-451-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5427225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist