Healthcare Provider Details

I. General information

NPI: 1336010784
Provider Name (Legal Business Name): OPAL PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 GIDDINGS AVE STE M1
ANNAPOLIS MD
21401-1411
US

IV. Provider business mailing address

770 RITCHIE HWY STE W23&W24
SEVERNA PARK MD
21146-4149
US

V. Phone/Fax

Practice location:
  • Phone: 443-906-1510
  • Fax: 443-906-1511
Mailing address:
  • Phone: 443-906-1510
  • Fax: 443-906-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA L TALLMAN
Title or Position: OWNER
Credential:
Phone: 410-721-7201