Healthcare Provider Details

I. General information

NPI: 1649871278
Provider Name (Legal Business Name): WILLIAM MATTISE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 FISHER RD
ROCHESTER NY
14624-3444
US

IV. Provider business mailing address

PO BOX 725
MENDON NY
14506-0725
US

V. Phone/Fax

Practice location:
  • Phone: 585-247-0270
  • Fax:
Mailing address:
  • Phone: 585-582-6273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number046511
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: