MEDICARE: HEADWATERS RESTORATION THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1154197283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEADWATERS RESTORATION THERAPY LLC

Provider Business Mailing Address
First Line	:	14689 GARRETT HWY
Second Line	:
City	:	OAKLAND
State	:	MD
Zip	:	21550-4059
Country	:	US
Telephone Number	:	301-859-7178
Fax Number	:	240-270-5229

Provider Business Practice Location Address
First Line	:	14689 GARRETT HWY STE 3
Second Line	:
City	:	OAKLAND
State	:	MD
Zip	:	21550-4059
Country	:	US
Telephone Number	:	301-859-7178
Fax Number	:	240-270-5229

Authorized Official
Title or Position	:	PROVIDER
Name	:	TAYLOR RYAN CRABTREE
Credential	:	CRNP
Telephone Number	:	304-777-7467

Provider Enumeration Date	:	11/29/2023
Last Update Date	:	01/12/2026

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