Healthcare Provider Details

I. General information

NPI: 1235516956
Provider Name (Legal Business Name): NRH/CPT/ST.MARY/CIVISTA REGIONAL REHABILITATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 POST OFFICE RD SUITE 105
WALDORF MD
20602-2756
US

IV. Provider business mailing address

20410 CENTURY BLVD SUITE 215
GERMANTOWN MD
20874-1186
US

V. Phone/Fax

Practice location:
  • Phone: 301-373-2588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN BRICKLEY
Title or Position: VICE PRESIDENT AMBULATORY OPERATION
Credential:
Phone: 301-540-6140