Provider Demographics
NPI:1770007411
Name:IMPACT SPORTS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:IMPACT SPORTS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ESBRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT, PES
Authorized Official - Phone:410-322-9777
Mailing Address - Street 1:8816 DOVE DR
Mailing Address - Street 2:
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-9000
Mailing Address - Country:US
Mailing Address - Phone:410-322-9777
Mailing Address - Fax:443-632-0521
Practice Address - Street 1:7468 CANDLEWOOD RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-3211
Practice Address - Country:US
Practice Address - Phone:410-684-5642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013316884OtherINDIVIDUAL NPI ROBERT ESBRANDT
1780097113OtherINDIVIDUAL NPI
W18167155OtherLLC ID #
25008OtherMARYLAND PT LICENSE