Healthcare Provider Details

I. General information

NPI: 1275731903
Provider Name (Legal Business Name): SERENA B MATTHEWS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11287 FIELDSTONE NELN
BAINBRIDGE ISLAND WA
98110-4282
US

IV. Provider business mailing address

11287 FIELDSTONE LN NE
BAINBRIDGE ISLAND WA
98110-4282
US

V. Phone/Fax

Practice location:
  • Phone: 206-718-0795
  • Fax:
Mailing address:
  • Phone: 206-855-8698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT00003730
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT00003730
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: