Healthcare Provider Details

I. General information

NPI: 1831493030
Provider Name (Legal Business Name): EVIDENCE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 ANNAPOLIS RD STE 201
GLENN DALE MD
20769
US

IV. Provider business mailing address

12150 ANNAPOLIS RD SUITE 201
GLENN DALE MD
20769-9183
US

V. Phone/Fax

Practice location:
  • Phone: 301-352-8370
  • Fax: 301-352-8372
Mailing address:
  • Phone: 301-352-8370
  • Fax: 301-352-8372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number21846
License Number StateMD

VIII. Authorized Official

Name: MRS. HASSANA MOSES
Title or Position: PRACTICE ADMINISTRATOR
Credential: SHRM-CP
Phone: 301-352-8370