Provider Demographics
NPI:1346846920
Name:PETENBRINK, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:PETENBRINK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 OLD FRIDINGER MILL RD
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-3335
Mailing Address - Country:US
Mailing Address - Phone:240-409-7915
Mailing Address - Fax:
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
Practice Address - Country:US
Practice Address - Phone:410-753-3317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2023-12-21
Deactivation Date:2021-09-09
Deactivation Code:
Reactivation Date:2021-12-03
Provider Licenses
StateLicense IDTaxonomies
225100000X, 390200000X
MD28742225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program