Basic Information
| Provider Information | |||||||||
| NPI: | 1033129853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYCZ | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9746 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041045040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078282449 | ||||||||
| FaxNumber: | 2078287850 | ||||||||
| Practice Location | |||||||||
| Address1: | 74 BARIBEAU DR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040113218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077984050 | ||||||||
| FaxNumber: | 2077984018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 06/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2305 | ME | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.