Provider Demographics
NPI:1730791450
Name:MANNICK, MATTHEW PAUL (DPT, ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:MANNICK
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 HUGHES FORD RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3134
Mailing Address - Country:US
Mailing Address - Phone:301-450-8038
Mailing Address - Fax:
Practice Address - Street 1:1341 HUGHES FORD RD STE 104
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-3134
Practice Address - Country:US
Practice Address - Phone:301-450-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30227225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist