Provider Demographics
NPI:1225719388
Name:DEMERS, MATTESON
Entity type:Individual
Prefix:
First Name:MATTESON
Middle Name:
Last Name:DEMERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-7081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-7081
Practice Address - Country:US
Practice Address - Phone:703-696-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0020170225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist