Provider Demographics
NPI:1861930935
Name:BERMINGHAM, MATTI (ATC, LAT, LMT)
Entity type:Individual
Prefix:
First Name:MATTI
Middle Name:
Last Name:BERMINGHAM
Suffix:
Gender:F
Credentials:ATC, LAT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 UNION BLVD STE 650
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-6512
Mailing Address - Country:US
Mailing Address - Phone:406-498-0483
Mailing Address - Fax:
Practice Address - Street 1:390 UNION BLVD
Practice Address - Street 2:#650
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1510
Practice Address - Country:US
Practice Address - Phone:406-498-0483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0017978225700000X, 204C00000X
COAT.00013552255A2300X, 2081S0010X, 2083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine