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General NPI Number Information
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NPI Number | 1396836052
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Entity Type | Organization
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Legal Business Name | ACTIVE LIFE & SPORTS THERAPY LLC
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Dates
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Enumeration Date | 09/27/2006
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Last Update Date | 01/12/2009
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Provider Practice Location Address
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Address Line | 4337 EBENEZER RD
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City | NOTTINGHAM
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State | MD
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Zip | 21236-2143
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Country | US
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Telephone | 410-529-3303
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Fax | 410-529-7980
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Provider Business Mailing Address
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Address Line | 4 DULANEY GATE CT
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City | COCKEYSVILLE
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State | MD
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Zip | 21030-3011
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Country | US
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Telephone | 410-529-3303
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Fax | 410-529-7980
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MICHAEL DAVID WAH
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Credential | PT
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Telephone | 410-529-3303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 15366
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License Number State | MD
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