Provider Demographics
NPI:1629745161
Name:CHAN, AMANDA C (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:CHAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:703 GRANITE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:540 GALLIVAN BLVD STE 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5463
Practice Address - Country:US
Practice Address - Phone:617-282-8080
Practice Address - Fax:617-282-9988
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA25666225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist