Provider Demographics
NPI:1598900219
Name:EMBRACK, EMIKA (PT)
Entity Type:Individual
Prefix:
First Name:EMIKA
Middle Name:
Last Name:EMBRACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8926 WOODYARD RD
Mailing Address - Street 2:SUITE 701
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4220
Mailing Address - Country:US
Mailing Address - Phone:301-856-1682
Mailing Address - Fax:
Practice Address - Street 1:11325 PEMBROOKE SQ
Practice Address - Street 2:SUITE 115
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4807
Practice Address - Country:US
Practice Address - Phone:301-719-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
94834201OtherCAREFIRST BCBS MARYLAND
166204YZWOtherDC MEDICARE PTAN
46950036OtherCAREFIRST BCBS NCA
22690OtherMARYLAND LICENSE