Basic Information
Provider Information | |||||||||
NPI: | 1073859476 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHESAPEAKE BAY AQUATIC & PHYSICAL THERAPY INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4058 | ||||||||
Address2: |   | ||||||||
City: | CROFTON | ||||||||
State: | MD | ||||||||
PostalCode: | 211144058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3012625852 | ||||||||
FaxNumber: | 3012623173 | ||||||||
Practice Location | |||||||||
Address1: | 9475 DEERECO RD STE 102 | ||||||||
Address2: |   | ||||||||
City: | TIMONIUM | ||||||||
State: | MD | ||||||||
PostalCode: | 210932124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103083543 | ||||||||
FaxNumber: | 4103084661 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2012 | ||||||||
LastUpdateDate: | 11/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOLDSTEIN | ||||||||
AuthorizedOfficialFirstName: | DANIELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 3014982212 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPT | ||||||||
NPICertificationDate: | 11/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.