Provider Demographics
NPI:1467880971
Name:SMITH, AMANDA ELIZABETH (MS, OTRL)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ELIZABETH
Other - Last Name:THEISEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTRL
Mailing Address - Street 1:18501 ROTUNDA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3891
Mailing Address - Country:US
Mailing Address - Phone:313-996-1930
Mailing Address - Fax:313-996-1935
Practice Address - Street 1:18501 ROTUNDA DR STE 100
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3891
Practice Address - Country:US
Practice Address - Phone:313-996-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-18
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008628225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty