Healthcare Provider Details

I. General information

NPI: 1659735058
Provider Name (Legal Business Name): GLEN BURNIE PHYSICAL THERAPY & SPORTSCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 MAGOTHY BEACH RD SUITE 105
PASADENA MD
21122-4423
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 410-437-3333
  • Fax:
Mailing address:
  • Phone: 252-248-3313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TASHEDA BROUGHTON
Title or Position: MANAGER, CREDENTIALING
Credential: PESC
Phone: 252-248-3313