Basic Information
| Provider Information | |||||||||
| NPI: | 1033776018 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GADDIE | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1410 DR MARTIN LUTHER KING JR STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277261181 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1410 DR MARTIN LUTHER KING JR STREET NORTH | ||||||||
| Address2: | |||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 43695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277261181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2019 | ||||||||
| LastUpdateDate: | 05/24/2019 | ||||||||
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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 | 224Z00000X | OTA15574 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | OTA15574 | 01 | FL | OTA | OTHER |