Provider Demographics
NPI:1912087198
Name:MARINO, MATTHEW CHRISTOPHER (MSPT, CEA, CWCHP)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:CHRISTOPHER
Last Name:MARINO
Suffix:
Gender:M
Credentials:MSPT, CEA, CWCHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9214 SW SALMON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6771
Mailing Address - Country:US
Mailing Address - Phone:503-863-6062
Mailing Address - Fax:
Practice Address - Street 1:9214 SW SALMON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6771
Practice Address - Country:US
Practice Address - Phone:503-863-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17659225100000X
OR5560225100000X
WAPT00010844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY69824Medicare ID - Type Unspecified