Provider Demographics
NPI:1306907506
Name:MATUSZAK, NICHOLE MARIE (DPT)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:MATUSZAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:WANATAH
Mailing Address - State:IN
Mailing Address - Zip Code:46390
Mailing Address - Country:US
Mailing Address - Phone:219-241-5593
Mailing Address - Fax:
Practice Address - Street 1:1120 S CALUMET RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3285
Practice Address - Country:US
Practice Address - Phone:219-983-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008714A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
249380AMedicare ID - Type Unspecified