Provider Demographics
NPI:1013166339
Name:WHITLOCK, AMANDA M (MSPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 LAKE MICHIGAN DR NW STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-6300
Mailing Address - Country:US
Mailing Address - Phone:616-791-7025
Mailing Address - Fax:
Practice Address - Street 1:4120 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9655
Practice Address - Country:US
Practice Address - Phone:616-365-2709
Practice Address - Fax:616-975-9248
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-018957225100000X
MI55010129933225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist