Provider Demographics
NPI:1902584139
Name:SIMONETTI, MATTHEW TRIER (LMT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TRIER
Last Name:SIMONETTI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 BELGROVE DR # 2
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-1508
Mailing Address - Country:US
Mailing Address - Phone:201-280-1375
Mailing Address - Fax:
Practice Address - Street 1:188 BELGROVE DR # 2
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-1508
Practice Address - Country:US
Practice Address - Phone:201-280-1375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00519800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist