Healthcare Provider Details

I. General information

NPI: 1174349575
Provider Name (Legal Business Name): ACTIVE 360 THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6212 YORK RD
BALTIMORE MD
21212-2612
US

IV. Provider business mailing address

6801 OAK HALL LN UNIT 6462
COLUMBIA MD
21045-7587
US

V. Phone/Fax

Practice location:
  • Phone: 301-776-8103
  • Fax: 410-755-7797
Mailing address:
  • Phone: 301-776-8103
  • Fax: 410-755-7797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CALISTA CHANA
Title or Position: CEO
Credential:
Phone: 301-776-8103