Provider Demographics
NPI:1750061651
Name:WALWORTH, AMANDA (LPTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WALWORTH
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4498 OLD CARRIAGE RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-5622
Mailing Address - Country:US
Mailing Address - Phone:810-965-8997
Mailing Address - Fax:
Practice Address - Street 1:9317 VIENNA RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:MI
Practice Address - Zip Code:48457-9729
Practice Address - Country:US
Practice Address - Phone:810-639-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502005036225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant