Provider Demographics
NPI:1023040128
Name:PROACTIVE THERAPY, LLC
Entity Type:Organization
Organization Name:PROACTIVE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRELL
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:202-409-9895
Mailing Address - Street 1:1016 BOOTH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21223-2527
Mailing Address - Country:US
Mailing Address - Phone:202-409-9895
Mailing Address - Fax:202-470-0423
Practice Address - Street 1:1016 BOOTH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2527
Practice Address - Country:US
Practice Address - Phone:202-409-9895
Practice Address - Fax:202-470-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17825225100000X
MD04737225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD761M320FMedicare ID - Type UnspecifiedGROUP - O.T.
MD621RMedicare ID - Type UnspecifiedP.T.
MD761M319FMedicare ID - Type UnspecifiedGROUP