Healthcare Provider Details

I. General information

NPI: 1255258455
Provider Name (Legal Business Name): MIKAYLA MATOS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 DIVISION ST
PAWTUCKET RI
02860-5352
US

IV. Provider business mailing address

4 RICHMOND SQ
PROVIDENCE RI
02906-5117
US

V. Phone/Fax

Practice location:
  • Phone: 401-226-0545
  • Fax: 401-721-5214
Mailing address:
  • Phone: 401-433-4172
  • Fax: 401-433-6012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT04142
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: