Provider Demographics
NPI:1982106530
Name:STEVENS, MATTHEW LEE (PTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W POWNAL RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:NORTH YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04097-6815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:895 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-9673
Practice Address - Country:US
Practice Address - Phone:207-439-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA4963225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant