Provider Demographics
NPI:1669973319
Name:WEIDNER, AMANDA LYNNE (PT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNNE
Last Name:WEIDNER
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 1:53581 DEERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-6395
Mailing Address - Country:US
Mailing Address - Phone:586-292-6005
Mailing Address - Fax:
Practice Address - Street 1:23715 LITTLE MACK AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1181
Practice Address - Country:US
Practice Address - Phone:586-447-4064
Practice Address - Fax:586-447-4069
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1932396017Medicaid