Provider Demographics
NPI:1336637883
Name:TABBERT, AMANDA JOYCE (OTRL)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOYCE
Last Name:TABBERT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 RANDY DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-1758
Mailing Address - Country:US
Mailing Address - Phone:734-260-8426
Mailing Address - Fax:
Practice Address - Street 1:36137 WARREN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2027
Practice Address - Country:US
Practice Address - Phone:734-728-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006134225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist