Provider Demographics
NPI:1952794224
Name:SUMRALL, MATTHEW STEPHEN (COTA/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:STEPHEN
Last Name:SUMRALL
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 SUNSCOPE DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8690
Mailing Address - Country:US
Mailing Address - Phone:228-875-1177
Mailing Address - Fax:228-872-4009
Practice Address - Street 1:6520 SUNSCOPE DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-8690
Practice Address - Country:US
Practice Address - Phone:228-875-1177
Practice Address - Fax:228-872-4009
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2602224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant