Provider Demographics
NPI:1699174821
Name:MACLEOD, MATTHEW (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MACLEOD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 441146
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30160-9522
Mailing Address - Country:US
Mailing Address - Phone:770-917-1935
Mailing Address - Fax:
Practice Address - Street 1:1030 GRANT ST SE UNIT 3
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-2015
Practice Address - Country:US
Practice Address - Phone:404-565-4064
Practice Address - Fax:678-550-9303
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist