Provider Demographics
NPI:1144581737
Name:GROSSMAN, AMY C (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:C
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1095 TEXAS PALMYRA HWY
Mailing Address - Street 2:STE 1
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-7687
Mailing Address - Country:US
Mailing Address - Phone:570-616-0665
Mailing Address - Fax:570-616-0669
Practice Address - Street 1:1095 TEXAS PALMYRA HWY
Practice Address - Street 2:STE 1
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-7687
Practice Address - Country:US
Practice Address - Phone:570-616-0665
Practice Address - Fax:570-616-0669
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008544L225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033697690001Medicaid