Healthcare Provider Details

I. General information

NPI: 1144571852
Provider Name (Legal Business Name): MATTHEW AARON LEARY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 HOSPITAL RD BUILDING B
FORT WALTON BEACH FL
32547-6778
US

IV. Provider business mailing address

PO BOX 242186
MONTGOMERY AL
36124-2186
US

V. Phone/Fax

Practice location:
  • Phone: 866-464-3878
  • Fax: 334-396-4905
Mailing address:
  • Phone: 334-625-5795
  • Fax: 334-396-4905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT27390
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: