Provider Demographics
NPI:1285276634
Name:MATUSEVICE, SIMONE (PTA)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:MATUSEVICE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 TUTTLE RD APT 6M
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-3633
Mailing Address - Country:US
Mailing Address - Phone:203-568-4469
Mailing Address - Fax:
Practice Address - Street 1:302 TUTTLE RD APT 6M
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-3633
Practice Address - Country:US
Practice Address - Phone:203-568-4469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001557225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant