Healthcare Provider Details

I. General information

NPI: 1467513978
Provider Name (Legal Business Name): CHESAPEAKE PHYSICAL AQUATIC THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7080 DEEPAGE DR
COLUMBIA MD
21045-5219
US

IV. Provider business mailing address

314 MARSHALL AVE
LAUREL MD
20707-4823
US

V. Phone/Fax

Practice location:
  • Phone: 410-381-7000
  • Fax: 410-381-3779
Mailing address:
  • Phone: 301-498-2212
  • Fax: 301-498-2213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number19690
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number19690
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number19690
License Number StateMD

VIII. Authorized Official

Name: MR. JARED S GOLDSTEIN
Title or Position: OWNER
Credential: PT
Phone: 410-381-7000