Provider Demographics
NPI:1295180487
Name:MOUNT WASHINGTON PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MOUNT WASHINGTON PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:410-913-9829
Mailing Address - Street 1:2201 CROSS COUNTRY BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4223
Mailing Address - Country:US
Mailing Address - Phone:410-913-9829
Mailing Address - Fax:
Practice Address - Street 1:1501 SULGRAVE AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3654
Practice Address - Country:US
Practice Address - Phone:410-542-6878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18331261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy