Basic Information
| Provider Information | |||||||||
| NPI: | 1558875906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTIOLI | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 EAGLE AVE | ||||||||
| Address2: | |||||||||
| City: | OCEAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077127631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322167602 | ||||||||
| FaxNumber: | 7326606222 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 EAGLE AVE | ||||||||
| Address2: | |||||||||
| City: | OCEAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077127631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322167602 | ||||||||
| FaxNumber: | 7326606222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2017 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 40QB00344100 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.