Provider Demographics
NPI:1144730888
Name:SPIESS, MATTHEW JOHN (AT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:SPIESS
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 LERNER WAY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-6004
Mailing Address - Country:US
Mailing Address - Phone:260-226-0009
Mailing Address - Fax:
Practice Address - Street 1:501 W SICKLES ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2173
Practice Address - Country:US
Practice Address - Phone:989-227-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010009012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer