=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245519008
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW T CAPPETTA OTR/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2011
-----------------------------------------------------
Last Update Date | 08/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 DAKOTA AVE
-----------------------------------------------------
City | SOUTH SIOUX CITY
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68776-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 140-249-5344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5405 STONE AVE
-----------------------------------------------------
City | SIOUX CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51106-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 1554
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------