Provider Demographics
NPI:1336558048
Name:MATLOCK, MATT (DPT)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:MATLOCK
Suffix:
Gender:M
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:PO BOX 242278
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-2278
Mailing Address - Country:US
Mailing Address - Phone:334-396-3273
Mailing Address - Fax:334-396-4905
Practice Address - Street 1:7061 HALCYON SUMMIT DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-6927
Practice Address - Country:US
Practice Address - Phone:334-396-2110
Practice Address - Fax:334-396-2115
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7084225100000X
GAPT011483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist