Basic Information
| Provider Information | |||||||||
| NPI: | 1538783246 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANFORD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | BRIAN | ||||||||
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| Credential: | MSOTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 VILLAGE GREEN CIR | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN TOP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187071710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705744126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 E END BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708243521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2020 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation |
No ID Information.