Provider Demographics
NPI:1811604093
Name:MATHEWS, MARTY J
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:J
Last Name:MATHEWS
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 1:28425 BELCOURT RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5623
Mailing Address - Country:US
Mailing Address - Phone:216-262-2223
Mailing Address - Fax:
Practice Address - Street 1:28425 BELCOURT RD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5623
Practice Address - Country:US
Practice Address - Phone:216-262-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services