Healthcare Provider Details

I. General information

NPI: 1891628590
Provider Name (Legal Business Name): MACKENZIE RAE WHITTAKER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4924 CAMPBELL BLVD
NOTTINGHAM MD
21236-5908
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 443-442-2700
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number30897
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: