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General NPI Number Information
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NPI Number | 1013660240
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Entity Type | Individual
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Provider Name | MR. MATTHEW GUTSTADT
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Gender | Male
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Dates
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Enumeration Date | 01/28/2022
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Last Update Date | 01/29/2022
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Provider Practice Location Address
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Address Line | 750 NE 24TH WAY
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City | FT LAUDERDALE
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State | FL
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Zip | 33304-3569
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Country | US
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Telephone | 954-557-0319
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Fax |
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Provider Business Mailing Address
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Address Line | 750 NE 24TH WAY
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City | FT LAUDERDALE
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State | FL
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Zip | 33304-3569
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Country | US
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Telephone | 954-557-0319
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 000787000
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License Number State | FL
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