Healthcare Provider Details

I. General information

NPI: 1417735788
Provider Name (Legal Business Name): MATTHEW GRYZLO COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 WOODBINE RD
PHILLIPSBURG NJ
08865-2263
US

IV. Provider business mailing address

29 WOODBINE RD
PHILLIPSBURG NJ
08865-2263
US

V. Phone/Fax

Practice location:
  • Phone: 908-246-7604
  • Fax:
Mailing address:
  • Phone: 908-246-7604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number46TA09174000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP010186
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: