Basic Information
| Provider Information | |||||||||
| NPI: | 1033875026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALILO | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ELLIS | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5842 220TH ST BAY BAYSIDE | ||||||||
| Address2: | |||||||||
| City: | BAYSIDE HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113641944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9172381323 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2579 OCEAN AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112294552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467800926 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2021 | ||||||||
| LastUpdateDate: | 11/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 026153 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.