Healthcare Provider Details

I. General information

NPI: 1023040128
Provider Name (Legal Business Name): PROACTIVE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/11/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 BOOTH ST
BALTIMORE MD
21223-2527
US

IV. Provider business mailing address

1016 BOOTH ST
BALTIMORE MD
21223-2527
US

V. Phone/Fax

Practice location:
  • Phone: 202-409-9895
  • Fax: 202-470-0423
Mailing address:
  • Phone: 202-409-9895
  • Fax: 202-470-0423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number17825
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number04737
License Number StateMD

VIII. Authorized Official

Name: TERRELL D. TRENT
Title or Position: OWNER
Credential: OT
Phone: 202-409-9895