Healthcare Provider Details

I. General information

NPI: 1912004268
Provider Name (Legal Business Name): WILLIAM CHARLES TESSENDORF MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 STREAKER ROAD
SYKESVILLE MD
21784-8654
US

IV. Provider business mailing address

450 STREAKER ROAD
SYKESVILLE MD
21784-8654
US

V. Phone/Fax

Practice location:
  • Phone: 410-552-1064
  • Fax: 410-701-4103
Mailing address:
  • Phone: 410-552-1064
  • Fax: 410-701-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberA0000067
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberAT000164
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: