Healthcare Provider Details

I. General information

NPI: 1508939448
Provider Name (Legal Business Name): MASSOUD TALAIE RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11404 OLD GEORGETOWN RD STE 104
ROCKVILLE MD
20852-2892
US

IV. Provider business mailing address

11404 OLD GEORGETOWN RD STE 104
ROCKVILLE MD
20852-2892
US

V. Phone/Fax

Practice location:
  • Phone: 240-833-2072
  • Fax: 240-465-0429
Mailing address:
  • Phone: 240-833-2072
  • Fax: 240-465-0429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15789
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number15789
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number15789
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: