Provider Demographics
NPI:1538442298
Name:HARTL, MATTHEW DOUGLAS (COTA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DOUGLAS
Last Name:HARTL
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1025
Mailing Address - Country:US
Mailing Address - Phone:607-749-1240
Mailing Address - Fax:
Practice Address - Street 1:58 CLINTON ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077-1025
Practice Address - Country:US
Practice Address - Phone:607-749-1240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003329-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant