Provider Demographics
NPI:1699397802
Name:PISANI, AMANDA (OTR/L, QMHP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PISANI
Suffix:
Gender:F
Credentials:OTR/L, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3642 N WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3714
Mailing Address - Country:US
Mailing Address - Phone:773-208-2063
Mailing Address - Fax:
Practice Address - Street 1:1400 W GREENLEAF AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-2805
Practice Address - Country:US
Practice Address - Phone:773-508-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.013503225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist