Provider Demographics
NPI:1124083910
Name:PLACH, MATTHEW (OT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PLACH
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W178N9201 WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-8029
Mailing Address - Country:US
Mailing Address - Phone:262-532-7240
Mailing Address - Fax:
Practice Address - Street 1:W178N9201 WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-8029
Practice Address - Country:US
Practice Address - Phone:262-532-7240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3774225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40883000Medicaid
WI40883000Medicaid
WIQ33068Medicare UPIN
WI81073Medicare PIN