Provider Demographics
NPI:1104173285
Name:BATES, MATT CHARLES CASSIDY (DPT)
Entity type:Individual
Prefix:MR
First Name:MATT
Middle Name:CHARLES CASSIDY
Last Name:BATES
Suffix:
Gender:M
Credentials:DPT
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Mailing Address - Street 1:5510 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2320
Mailing Address - Country:US
Mailing Address - Phone:304-720-5433
Mailing Address - Fax:304-720-5436
Practice Address - Street 1:1803 FOREST HILLS RD W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3412
Practice Address - Country:US
Practice Address - Phone:252-243-9629
Practice Address - Fax:919-313-1276
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NCP14489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP14489OtherPT LICENSE NUMBER