Provider Demographics
NPI:1457821191
Name:TRAIL, AMANDA (PT, DPT, CLT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TRAIL
Suffix:
Gender:F
Credentials:PT, DPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3774 HOLLYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9550
Mailing Address - Country:US
Mailing Address - Phone:269-428-2799
Mailing Address - Fax:
Practice Address - Street 1:3774 HOLLYWOOD RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9550
Practice Address - Country:US
Practice Address - Phone:269-428-2799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist