Healthcare Provider Details

I. General information

NPI: 1255082723
Provider Name (Legal Business Name): PIVOT PHYSICAL THERAPY OF CENTRAL MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2022
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 THOMAS JOHNSON DR STE M
FREDERICK MD
21702-4895
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 301-698-9761
  • Fax:
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: TASHEDA BROUGHTON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 919-258-2714