Provider Demographics
NPI:1326867136
Name:WILSON, MATTHEW DAVID (RADT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90294-1554
Mailing Address - Country:US
Mailing Address - Phone:206-902-0769
Mailing Address - Fax:
Practice Address - Street 1:14515 HAMLIN ST STE 100
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1694
Practice Address - Country:US
Practice Address - Phone:206-902-0769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1462230322225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner