Provider Demographics
NPI:1841475027
Name:CLEMENTZ, AMANDA (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CLEMENTZ
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 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-8923
Mailing Address - Fax:309-672-4569
Practice Address - Street 1:7938 GA HIGHWAY 21 STE 300
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-9808
Practice Address - Country:US
Practice Address - Phone:912-965-0601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016003225100000X
IL070013744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01141585OtherRR MEDICARE
ILP01141585OtherRR MEDICARE