Basic Information
| Provider Information | |||||||||
| NPI: | 1760714059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESAPEAKE BAY AQUATIC & PHYSICAL THERAPY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4058 | ||||||||
| Address2: | |||||||||
| City: | CROFTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211144058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012625852 | ||||||||
| FaxNumber: | 3012623173 | ||||||||
| Practice Location | |||||||||
| Address1: | 13946 BALTIMORE AVE | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207075000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014982212 | ||||||||
| FaxNumber: | 3014982213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2010 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOLDSTEIN | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3014982212 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.