Provider Demographics
NPI:1932689320
Name:GAIKWAD, AMANDA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:GAIKWAD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1047
Mailing Address - Country:US
Mailing Address - Phone:708-829-0491
Mailing Address - Fax:
Practice Address - Street 1:1601 BUTTERFIELD TRL
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2959
Practice Address - Country:US
Practice Address - Phone:815-936-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist