Provider Demographics
NPI:1194295618
Name:RESENER, MATTHEW WAYNE (COTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:RESENER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:WAYNE
Other - Last Name:RESENER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:63 MALDEN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1005
Mailing Address - Country:US
Mailing Address - Phone:508-615-2512
Mailing Address - Fax:
Practice Address - Street 1:63 MALDEN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-1005
Practice Address - Country:US
Practice Address - Phone:508-615-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4102224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS33872023OtherDRIVER LICENSE