# ACTIVE LIFE & SPORTS THERAPY LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1396836052
- **Authorized official:** JOSEPH PALMER (OWNER, PRESIDENT)
- **Authorized official phone:** (410) 949-6639

## Contact information

- **Practice address:** 4337 EBENEZER RD, NOTTINGHAM, MD 21236-2143
- **Practice address phone:** (410) 529-3303
- **Practice address fax:** (410) 529-7980
- **Mailing address:** 4337 EBENEZER RD, NOTTINGHAM, MD 21236-2143
- **Mailing address phone:** (410) 529-3303
- **Mailing address fax:** (410) 529-7980

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | 15366 | MD | Yes |

## Other

- **Enumeration date:** 09/27/2006
- **Last updated:** 03/11/2026

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 434M | MEDICARE PTAN | MD |
| 01 | — | 6400507 | AARP | MD |
| 01 | — | DA1789 | RAILROAD MEDICARE | MD |
| 01 | — | F517 | GHMSI | MD |
| 01 | — | KCH3AC | CAREFIRST OF MD | MD |