Provider Demographics
NPI:1538494588
Name:MATTICE, MIKEL ANN (OTA)
Entity type:Individual
Prefix:MISS
First Name:MIKEL
Middle Name:ANN
Last Name:MATTICE
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 SWAGGERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-3918
Mailing Address - Country:US
Mailing Address - Phone:518-382-2074
Mailing Address - Fax:
Practice Address - Street 1:411 SWAGGERTOWN RD
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-3918
Practice Address - Country:US
Practice Address - Phone:518-382-2074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0073671224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant