Provider Demographics
NPI:1154197283
Name:HEADWATERS RESTORATION THERAPY LLC
Entity type:Organization
Organization Name:HEADWATERS RESTORATION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:CRABTREE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:304-777-7467
Mailing Address - Street 1:3601 UNDERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-2116
Mailing Address - Country:US
Mailing Address - Phone:240-321-9961
Mailing Address - Fax:
Practice Address - Street 1:4000 THAYER CTR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1138
Practice Address - Country:US
Practice Address - Phone:240-321-9961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty