Provider Demographics
NPI:1043989304
Name:CARR, MATTHEW CEVIN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CEVIN
Last Name:CARR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13754 MANGO DR UNIT 117
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3433
Mailing Address - Country:US
Mailing Address - Phone:435-513-0871
Mailing Address - Fax:
Practice Address - Street 1:8515 COSTA VERDE BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1130
Practice Address - Country:US
Practice Address - Phone:888-674-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22745225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist