Provider Demographics
NPI:1609497593
Name:TAN, AMANDA BERNICE (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA BERNICE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 W HOWARD ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1200
Mailing Address - Country:US
Mailing Address - Phone:872-202-6231
Mailing Address - Fax:
Practice Address - Street 1:2815 W HOWARD ST APT 2E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1200
Practice Address - Country:US
Practice Address - Phone:872-202-6231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006690225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant