Provider Demographics
NPI:1790392058
Name:THORNBURG, TYLER JAMES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:THORNBURG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N CALVERT ST APT 1038
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4949
Mailing Address - Country:US
Mailing Address - Phone:304-780-4256
Mailing Address - Fax:
Practice Address - Street 1:1207 LIBERTY RD # 106
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6574
Practice Address - Country:US
Practice Address - Phone:410-549-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT004346225100000X
MD28140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist