Basic Information
| Provider Information | |||||||||
| NPI: | 1194023309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTHESEN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPA OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2832 ROYLE ST | ||||||||
| Address2: | |||||||||
| City: | BELLMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117104131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166798553 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15050 14TH RD | ||||||||
| Address2: | |||||||||
| City: | WHITESTONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113572609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187670091 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 387-1 | NY | N | Other Service Providers | Specialist | 225X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.