Provider Demographics
NPI:1356691083
Name:ROBERTS AHMETI, AMANDA KAE (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAE
Last Name:ROBERTS AHMETI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KAE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:17615 W MOORE
Mailing Address - Street 2:P.O. BOX 518
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-9408
Mailing Address - Country:US
Mailing Address - Phone:231-834-0208
Mailing Address - Fax:231-834-0223
Practice Address - Street 1:601 MICHIGAN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4951
Practice Address - Country:US
Practice Address - Phone:616-355-4284
Practice Address - Fax:616-355-4285
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist