=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588890065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IN BALANCE PHYSICAL THERAPY AND WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2009
-----------------------------------------------------
Last Update Date | 05/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 CROSSROADS DR STE 210
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-948-6609
-----------------------------------------------------
Fax | 443-948-6610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 CROSSROADS DR STE 210
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-5483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-948-6609
-----------------------------------------------------
Fax | 443-948-6610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. JODI SAMARA BERGER
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 443-948-6609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251C2600X
-----------------------------------------------------
Taxonomy Name | Cardiopulmonary Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251G0304X
-----------------------------------------------------
Taxonomy Name | Geriatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 227800000X
-----------------------------------------------------
Taxonomy Name | Certified Respiratory Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 227900000X
-----------------------------------------------------
Taxonomy Name | Registered Respiratory Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------