Healthcare Provider Details

I. General information

NPI: 1902188485
Provider Name (Legal Business Name): AUDREY B BERSHAK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 QUARRY LAKE DR STE 300
BALTIMORE MD
21209-3746
US

IV. Provider business mailing address

2700 QUARRY LAKE DR STE 300
BALTIMORE MD
21209-3746
US

V. Phone/Fax

Practice location:
  • Phone: 410-377-8900
  • Fax: 410-377-0576
Mailing address:
  • Phone: 410-377-8900
  • Fax: 410-377-0576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number11630
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11630
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: