Provider Demographics
NPI:1679630073
Name:GLEN BURNIE PHYSICAL THERAPY & SPORTSCARE, LLC
Entity Type:Organization
Organization Name:GLEN BURNIE PHYSICAL THERAPY & SPORTSCARE, LLC
Other - Org Name:PASADENA GLEN BURNIE PT OFFICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TASHEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-248-3313
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:5500 KNOLL NORTH DR STE 150
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2476
Practice Address - Country:US
Practice Address - Phone:443-542-0062
Practice Address - Fax:443-542-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty