Provider Demographics
NPI:1821656950
Name:PICKWORTH-CHRUSCIEL, AMANDA ILLA (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ILLA
Last Name:PICKWORTH-CHRUSCIEL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ILLA
Other - Last Name:PICKWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5536 RESEARCH DR STE A
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2261
Mailing Address - Country:US
Mailing Address - Phone:734-895-1901
Mailing Address - Fax:855-794-1008
Practice Address - Street 1:17783 HAGGERTY RD STE B
Practice Address - Street 2:
Practice Address - City:NORTHVILLE CHARTER TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48168-9802
Practice Address - Country:US
Practice Address - Phone:734-895-1901
Practice Address - Fax:855-794-1008
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003904225200000X
MI5501303770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant