Provider Demographics
NPI:1366074585
Name:MATHENA, TYLER STORM (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:STORM
Last Name:MATHENA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 JEANETTE DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-1049
Mailing Address - Country:US
Mailing Address - Phone:434-770-0741
Mailing Address - Fax:
Practice Address - Street 1:2140 FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-5264
Practice Address - Country:US
Practice Address - Phone:434-836-4158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist