Provider Demographics
NPI:1124335245
Name:WALTERS, MATTHEW (PT, DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 DOE MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2064
Mailing Address - Country:US
Mailing Address - Phone:713-305-1614
Mailing Address - Fax:
Practice Address - Street 1:116 MERIDIAN WAY STE 9
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2876
Practice Address - Country:US
Practice Address - Phone:859-626-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007696225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100629730Medicaid