Provider Demographics
NPI:1053443630
Name:KUMPURIS, AMANDA MICHELE (AT,C)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MICHELE
Last Name:KUMPURIS
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15460 LAKESIDE VILLAGE DR
Mailing Address - Street 2:APT # 303
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11911 CLINTON RIVER RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-2420
Practice Address - Country:US
Practice Address - Phone:586-797-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer