Healthcare Provider Details

I. General information

NPI: 1639223381
Provider Name (Legal Business Name): CHESAPEAKE PHYSICAL AQUATIC THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHITE MARSH PARK DR
BOWIE MD
20715-4361
US

IV. Provider business mailing address

314 MARSHALL AVE
LAUREL MD
20707-4823
US

V. Phone/Fax

Practice location:
  • Phone: 301-262-5852
  • Fax: 301-262-3173
Mailing address:
  • Phone: 301-262-5852
  • Fax: 301-262-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. JARED STEWART GOLDSTEIN
Title or Position: OWNER
Credential: P.T.
Phone: 301-262-5852