Provider Demographics
NPI:1841641958
Name:MOEN, MATTHEW D (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:MOEN
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 1:2401 PLOVER RD
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-3916
Mailing Address - Country:US
Mailing Address - Phone:715-295-3800
Mailing Address - Fax:
Practice Address - Street 1:2401 PLOVER RD
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-3916
Practice Address - Country:US
Practice Address - Phone:715-295-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13530-24225100000X
IL070-022045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist