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General NPI Number Information
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NPI Number | 1154197283
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Entity Type | Organization
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Legal Business Name | HEADWATERS RESTORATION THERAPY LLC
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Dates
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Enumeration Date | 11/29/2023
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Last Update Date | 01/04/2026
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Provider Practice Location Address
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Address Line | 4000 THAYER CTR
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City | OAKLAND
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State | MD
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Zip | 21550-1138
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Country | US
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Telephone | 240-321-9961
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Fax |
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Provider Business Mailing Address
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Address Line | 14689 GARRETT HWY
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City | OAKLAND
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State | MD
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Zip | 21550-4059
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Country | US
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Telephone | 301-859-7178
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Fax | 240-270-5229
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Authorized Official
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Title or Position | PROVIDER
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Name | TAYLOR RYAN CRABTREE
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Credential | CRNP
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Telephone | 304-777-7467
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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