Healthcare Provider Details

I. General information

NPI: 1346846920
Provider Name (Legal Business Name): ALEXANDRA PETENBRINK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date: 09/09/2021
Reactivation Date: 12/03/2021

III. Provider practice location address

1838 GREENE TREE RD
PIKESVILLE MD
21208-6391
US

IV. Provider business mailing address

1234 OLD FRIDINGER MILL RD
WESTMINSTER MD
21157-3335
US

V. Phone/Fax

Practice location:
  • Phone: 410-753-3317
  • Fax:
Mailing address:
  • Phone: 240-409-7915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number28742
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: