Healthcare Provider Details

I. General information

NPI: 1710519806
Provider Name (Legal Business Name): SHAWNA RAE SPROUT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 09/24/2022
Certification Date: 09/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 MARTIN BLVD STE 5
MIDDLE RIVER MD
21220-4104
US

IV. Provider business mailing address

1364 MARTIN BLVD STE 5
MIDDLE RIVER MD
21220-4104
US

V. Phone/Fax

Practice location:
  • Phone: 410-686-3600
  • Fax:
Mailing address:
  • Phone: 410-686-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number28779
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT34907
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: